Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quincy Healthcare & Sr Living during CMS and state inspections, most recent first.
Failure to notify the resident’s representative and physician of an injury. A resident with multiple chronic conditions developed significant bruising to the arm, chest, ribs, and xiphoid area, but staff did not promptly complete an incident report or notify the MD and POA when the bruising was first observed. The POA later stated she was not informed until the resident was sent to the hospital, and the DON and administrator acknowledged the notifications should have occurred when the bruises were first seen.
A resident with multiple medical conditions requiring assistance for toileting waited several hours for staff to respond to her call light, resulting in her soiling herself and experiencing emotional distress. Facility policy requires call lights to be answered within five minutes, but staff failed to provide timely assistance, and the incident was confirmed by both the resident and a CNA.
A deficiency was identified when the facility failed to provide sufficient CNA staffing hours, resulting in unmet resident needs such as delayed call light responses, unassisted toileting, and lack of feeding assistance during meals. Multiple residents reported or were observed experiencing delays or lack of care, and staff interviews confirmed ongoing staffing shortages and burnout. The facility was also operating without a DON or Infection Control Preventionist, contributing to the inability to maintain adequate staffing levels.
The facility did not have a full-time DON in place after the previous DON stepped down and resumed duties as a floor nurse, leaving the DON position vacant for an interim period. This was confirmed by facility records and staff interviews, affecting all residents in the facility.
The facility did not have a qualified Infection Preventionist in place after the previous staff member left, leaving the infection prevention and control program without oversight for all residents. The Administrator in Training confirmed that no interim staff had been assigned to this role, despite facility policy and job descriptions requiring such coverage.
The facility did not post daily staffing sheets that included the total hours worked by CNAs, RNs, and LPNs for each 24-hour period. Instead, only lists of staff scheduled to work were posted, without the required breakdown of hours for each nursing role. This practice was confirmed by both administrative and scheduling staff, and affected all residents in the facility.
A resident with multiple health conditions fell during a transfer using a mechanical lift when a CNA operated the lift alone, against facility policy requiring two staff members. The resident was not positioned correctly in the wheelchair, leading to the fall. The CNA had a history of similar unsafe practices and was previously disciplined and retrained.
The facility failed to respond to call lights in a timely manner, as required by their policy, affecting three residents. One resident, cognitively intact, experienced waits of 30 minutes to an hour, with documented delays up to nearly two hours. Another resident with moderate cognitive impairment reported waits over 30 minutes, while a third resident faced delays of 15 minutes to two hours. The interim administrator cited issues with the call light system and recent leadership changes as contributing factors.
The facility failed to respond to residents' call lights in a timely manner, with documented delays of over two hours for some calls. Several residents expressed frustration over waiting for assistance, and the DON was unaware of the reasons for these delays, despite the facility's policy requiring prompt responses.
The facility failed to notify the Ombudsman of resident discharges and transfers and did not provide written transfer notices to residents and their representatives. This deficiency affected several residents who were transferred to hospitals without proper documentation or notification, as confirmed by facility staff.
The facility failed to provide bed hold notifications to residents or their representatives during hospital transfers, as required by policy. This deficiency affected five residents who were transferred to the hospital for various medical conditions, including congestive heart failure and leukocytosis. The Business Office Manager confirmed the lack of documentation for these notifications, violating the facility's policy.
The facility failed to follow its respiratory care policies, resulting in deficiencies such as undated and improperly stored oxygen and nebulizer equipment for several residents. One resident lacked an oxygen sign, and another had equipment lying on the floor. Staff were unaware of the requirements, leading to non-compliance with established protocols.
A long-term care facility failed to provide physician-ordered medications for four residents due to unavailability, resulting in missed doses. The facility's policy mandates 24/7 pharmaceutical services, but issues with the pharmacy led to medications like Levothyroxine, Spiriva, Metoprolol, and Furosemide being unavailable at the time of administration. An LPN noted ongoing problems with obtaining medications, necessitating reorders.
The facility failed to provide snacks and complete meals to residents, as six residents reported not receiving evening snacks and incomplete meal services, including missing beverages. The dietary manager was unaware of these issues, and the Director of Nursing confirmed that residents were not consistently receiving fresh ice water during each shift.
The facility failed to provide the required Medicare Advance Beneficiary Notice of Non-Coverage to two residents, as per the facility's policy. The Accounts Receivable staff could not provide documentation or confirm communication regarding the termination of Medicare A coverage for these residents, indicating a lapse in the notification process.
The facility failed to conduct required Level II PASRR screenings for two residents diagnosed with mental illness, as mandated by the Medicaid PASRR process. One resident with Schizoaffective Disorder and another with Schizophrenia, Anxiety Disorder, and Depressive Disorder did not receive the necessary evaluations. The DON confirmed the screenings were not requested, and the Administrator-In-Training expressed uncertainty about the process.
A resident experienced a decline in functional ability due to the facility's failure to provide necessary therapy or restorative services. Despite a change in transfer status from sit-to-stand to a non-weight bearing mechanical lift, the resident did not receive therapy to address this decline. The Physical Therapist cited altered mental status as a reason for not initiating therapy, and the lack of Interdisciplinary Team meetings contributed to the oversight.
A resident at moderate risk for pressure ulcers developed a Stage II ulcer due to the facility's failure to perform weekly skin checks and timely treatment. The resident was not repositioned as required, and staff were unaware of repositioning orders. The DON confirmed the ulcer was facility-acquired.
A resident with hemiplegia and muscle wasting did not receive necessary range of motion (ROM) exercises or therapy, despite having functional limitations in an upper extremity. The resident's care plan did not address these limitations, and the Restorative Aide confirmed the absence of a restorative program for ROM exercises, contrary to the facility's policy.
A facility failed to provide proper dialysis care for a resident with ESRD by not maintaining communication with the dialysis center, monitoring the dialysis access site, or documenting post-dialysis observations. The resident reported that facility staff did not monitor her access site, and the Director of Nursing confirmed the lack of communication and documentation. The resident's care plan lacked interventions for monitoring or emergency care of the dialysis access site.
The facility failed to document targeted behaviors and diagnoses to justify the use of antipsychotic medications for two residents with Dementia. Despite policy requirements for gradual dose reductions and non-pharmacological interventions, there was no documentation of evaluations or interdisciplinary team meetings to justify the continued use of these medications. Observations and staff interviews indicated the absence of significant behaviors that would warrant such medication use.
The facility failed to explain the arbitration agreement to residents or their representatives in a manner they could understand, did not state that the agreement could be rescinded within 30 days, and did not require acknowledgment of understanding. Interviews revealed that residents were unaware of the arbitration agreement and its implications, and a Power of Attorney was not informed about waiving litigation rights. The contract lacked provisions for rescinding the agreement and acknowledgment of understanding.
The facility failed to implement enhanced barrier precautions for 16 residents, including those with wounds and indwelling devices, despite having a policy in place. Staff were observed providing care without using gowns or gloves, and a registered nurse was unaware of the precautions. The facility administrator confirmed the policy had not been implemented.
A resident with a right heel unstageable pressure ulcer did not receive proper care as ordered. The resident's heels were not elevated, and heel protectors were not used. The dressing, which was supposed to be changed daily, was found to be soiled and dated six days prior. The nursing staff reused the foam bordered gauze against manufacturer's instructions, leading to inadequate care.
The facility failed to safely dispense medications to three residents. An LPN left medications at the bedside for residents to take later, without ensuring they were taken. The DON confirmed that nurses should not leave medications in residents' rooms without supervision.
A resident with multiple diagnoses did not receive their scheduled 7:00 am and 8:00 am medications, including insulin, until 9:35 am, after completing breakfast. The LPN and DON confirmed that medications should be administered at their scheduled times, highlighting a significant medication error.
Failure to Notify Physician and Representative of Resident Injury
Penalty
Summary
The facility failed to notify the resident’s representative and physician of an injury for one of three residents reviewed for quality of care. The resident had diagnoses including contracture of the left upper arm, type 2 diabetes mellitus, dysphagia, chronic kidney disease stage 3, anemia, vitamin D deficiency, atelectasis, soft tissue disorders, and muscle wasting and atrophy. Nursing documentation showed dark purple bruising to the inside of the left arm and yellow discoloration with dark purple bruising to the left side of the chest, followed by additional documentation of yellow bruising to the chest and sides, purple bruising near the ribcage, and a protruding xiphoid process. The resident denied pain or discomfort when assessed. The record also showed that the resident’s POA was not made aware of the bruising until the resident was sent to the hospital, and the POA stated she would have liked to have been notified when the bruising was found. A nurse stated she saw bruising on the resident’s chest and passed the information to the next shift but did not complete an incident report, call the doctor, or notify the POA. The administrator stated that as soon as the bruises were seen, an incident report should have been completed, the bruises measured and documented, and the family and physician notified at that time, but the administrator was not notified until later and that was when the investigation began.
Failure to Respond Timely to Call Light for Toileting Assistance
Penalty
Summary
The facility failed to ensure timely response to a resident's call light for toileting assistance, resulting in the resident soiling herself and remaining in that condition for several hours. The resident, who has diagnoses including urinary tract infection, chronic heart failure, respiratory failure, morbid obesity, and chronic kidney disease, requires assistance from staff for toileting due to her inability to transfer safely. On the evening in question, the resident requested help from a CNA, who stated she would return but did not. The resident then activated her call light, but no staff responded until several hours later, by which time she had already soiled herself and experienced significant emotional distress. Facility policies require that call lights be answered within five minutes and that residents be treated with dignity and respect, including prompt assistance with toileting. Interviews with the resident and a CNA confirmed the delay in response and the resident's resulting distress. The administrator in training was unaware of the incident prior to the surveyor's inquiry but acknowledged that such a delay in assistance is unacceptable.
Inadequate Staffing Leads to Unmet Resident Needs and Delayed Care
Penalty
Summary
The facility failed to provide adequate direct care staffing hours to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. The facility's own Facility Assessment indicated an expected 196 CNA hours per 24-hour period, but on the reviewed date, only 116 CNA hours were provided for 75 residents. Resident council minutes documented ongoing concerns about unmade beds, unchanged sheets, and delayed call light responses. Multiple residents reported that their requests for assistance were not answered in a timely manner, with one resident stating she soiled herself after waiting for help with toileting for several hours. During meal times, residents requiring assistance with eating were observed left unattended in the dining room, with no staff present to provide necessary support. Two residents were seen with full plates of uneaten food, one of whom was sleeping at the table, and another who required encouragement and physical assistance to eat. Staff interviews confirmed that CNA coverage was insufficient, with one CNA stating she was the only aide on her hall and unable to keep up with resident needs, especially for those requiring two-person transfers or feeding assistance. Further interviews with staff, including a LPN and the scheduler, revealed that staffing shortages had worsened over the past month due to call-ins and unfilled shifts. The scheduler was unaware of state minimum staffing requirements and acknowledged that staff were experiencing burnout and unwilling to work extra shifts. The facility also lacked a DON and an Infection Control Preventionist at the time of the survey, further impacting the ability to ensure adequate staffing and supervision.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide the services of a full-time Director of Nursing (DON) as required by its own Facility Assessment and job description. According to the Administrator in Training, a significant number of management staff, including the DON, stepped down from their positions on the same day. The former DON reverted to working as a floor nurse and ceased fulfilling DON responsibilities, leaving the facility without anyone in the DON role for an interim period. This lapse was confirmed by facility records and interviews, and at the time of the survey, the facility had 75 residents and no designated DON overseeing nursing services.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist to oversee the infection prevention and control program, as required by their own Facility Assessment and job descriptions. The Facility Assessment, dated 4/15/25, indicated that the facility would provide nursing services that include an Infection Preventionist, and the job description outlined specific infection control responsibilities. However, record review and interviews confirmed that the position was vacant after the previous Assistant Director of Nursing/Infection Control Preventionist left approximately two weeks prior to the survey, and no interim replacement had been assigned. At the time of the survey, the facility had 75 residents, and the Administrator in Training acknowledged that the Infection Preventionist role was unfilled due to multiple management staff resigning on the same day. The absence of a designated Infection Preventionist meant that no one was responsible for supervising infection control protocols, monitoring isolation procedures, or ensuring compliance with infection prevention standards as outlined in facility policy.
Failure to Post Required Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that daily staffing postings accurately documented the total number of hours worked by Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) for each 24-hour period. Review of daily staffing sheets posted from 3/25/25 to 4/25/25 revealed that none included the required total hours for each category of nursing staff. Instead, the postings only listed the names of employees scheduled to work each day, without specifying the breakdown of hours for RNs, LPNs, or CNAs. Interviews with facility staff confirmed that the posted staffing sheets, generated from the facility's scheduling system, did not provide the necessary hour totals for each nursing role. The Administrator In Training and the Human Resources/Scheduler both acknowledged that the current practice was to post only the list of staff on duty, and that this method had been in place prior to the current administrator's tenure. At the time of the survey, the facility had 75 residents, all of whom could be affected by the lack of proper staffing documentation.
Resident Fall Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to prevent a fall for a resident during a transfer using a mechanical sit-to-stand lift. The resident, a female with multiple diagnoses including End Stage Renal Disease and Chronic Kidney Disease, was dependent on staff for transfers and had an intact cognitive status. During the incident, the resident slid from her wheelchair to the floor while being transferred by a CNA who was operating the lift alone, contrary to the facility's policy requiring two staff members for such transfers. The CNA admitted to performing the transfer alone because other staff were busy, and the resident was not positioned correctly in the wheelchair, leading to the fall. The CNA involved had a history of similar incidents and had been previously disciplined and retrained for unsafe transfer practices. Despite this, the CNA continued to perform transfers alone, compromising resident safety. The facility's policy clearly mandates the presence of two staff members during mechanical lift transfers to ensure safety, but this was not adhered to, resulting in the resident's fall. The incident was documented by the facility's administrator and director of nursing, who confirmed the breach of policy and the CNA's failure to follow established procedures.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to ensure that call lights were answered in a reasonable amount of time for three residents, leading to a deficiency in honoring residents' rights to a dignified existence and self-determination. The facility's policy requires that calls for assistance be answered within five minutes, with urgent requests addressed immediately. However, the facility's Alarm Response Reports documented significant delays in response times for the residents. One resident, who is cognitively intact, reported waiting between 30 minutes to an hour on several occasions, with documented wait times ranging from 22 minutes to nearly two hours over several days. Another resident with moderate cognitive impairment reported waiting over 30 minutes on some occasions, with documented wait times exceeding 30 minutes on two specific days. A third resident, also cognitively intact, reported waiting between 15 minutes to two hours, with documented wait times frequently exceeding 30 minutes and reaching up to nearly three hours. The facility's interim administrator acknowledged issues with the call light system, noting that the screens at nurse stations do not sound, making it difficult for staff to be aware of active call lights. Additionally, the facility had recently lost their Director of Nursing, which may have contributed to the leadership gap affecting call light response times. The ombudsman confirmed receiving complaints about delayed call light responses, indicating a broader issue within the facility. These findings highlight a failure to adhere to the facility's policy and ensure timely assistance for residents, compromising their right to a dignified existence and self-determination.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to residents' call lights in a reasonable amount of time, as evidenced by the experiences of six residents. The facility's policy, dated September 2022, mandates that call lights should be answered as soon as possible, but no later than five minutes, with urgent requests addressed immediately. However, the Alarm Response Report for the week of August 18, 2024, through August 24, 2024, documented significant delays in response times. Two call lights were not answered for over two hours, and several others took over an hour to be addressed. Additional delays were noted, with numerous calls taking over 20 to 50 minutes to be answered. During a group meeting, several residents expressed their frustration with the prolonged wait times. They reported waiting for over an hour for assistance, with some instances where a CNA would turn off the call light but not return promptly. The Director of Nursing acknowledged that call lights should be answered in a reasonable time but was unaware of the reasons for the delays. The residents' testimonies and the documented response times highlight a significant deficiency in the facility's ability to meet the residents' needs for timely assistance.
Failure to Notify Ombudsman and Provide Transfer Notices
Penalty
Summary
The facility failed to notify the facility Ombudsman of resident discharges and transfers monthly, and did not provide written notice of transfer to the residents and their representatives for five residents reviewed in the sample. The facility's policy on Transfer or Discharge Documentation, dated December 2016, requires that details of the transfer or discharge be documented in the medical record and communicated to the receiving health care facility or provider. However, the facility did not adhere to this policy for residents R18, R33, R46, R66, and R75, as there was no evidence of notification to the family or ombudsman in their medical records. Specific instances include R18, who was admitted to the hospital with congestive heart failure and urinary tract infection, and R33, who was discharged to the hospital with possible dyspnea/aspiration pneumonia and acute renal insufficiency. Similarly, R75 was admitted to the hospital for leukocytosis, and R46 and R66 were also transferred to hospitals without proper notification. The Business Office Manager confirmed the lack of documentation for these residents, and the Service Director admitted to not including hospital transfers in the monthly list sent to the Ombudsman, indicating a gap in the facility's communication and documentation processes.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notifications to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified for five residents who were transferred to the hospital. The facility's Bed-Holds and Returns policy mandates that residents or their representatives receive written information about bed-hold policies both in advance of any transfer and at the time of transfer, or within 24 hours in the case of an emergency. However, for residents R18, R33, R46, R66, and R75, there was no evidence in their medical records that such notifications were provided. The deficiency was confirmed through interviews and record reviews. The Business Office Manager, responsible for tracking notices of transfers and bed holds, verified the lack of documentation for the affected residents. Specific instances included R18's transfer for congestive heart failure and other conditions, R33's transfer for dyspnea and other issues, and R75's transfer for leukocytosis, among others. Despite these transfers, the facility did not document the provision of bed hold notifications, violating their own policy and potentially impacting the residents' rights and understanding of their bed-hold status during hospital stays.
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to adhere to its respiratory care policies, resulting in several deficiencies. For one resident, there was no oxygen sign placed on the door or in the room, and the oxygen tubing and humidifier bottle were not dated as required. This resident had been readmitted with diagnoses including Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure with Hypoxia, and had a physician order for continuous oxygen. Additionally, another resident's oxygen tubing, nebulizer tubing, and nebulizer mask were found undated and unbagged, contrary to the facility's policy that mandates weekly changes and proper storage. Further observations revealed that another resident's oxygen tubing was lying on the floor undated, and the nasal cannula was uncovered, with the humidification bottle also undated. A Licensed Practical Nurse admitted to being unaware of the requirement to date the equipment. Similarly, another resident's nebulizer mask and tubing were found unbagged and undated on the nightstand, despite a physician order for regular nebulizer treatments. A Registered Nurse confirmed the oversight, noting that the night shift was responsible for changing and dating the equipment every seven days.
Medication Unavailability in LTC Facility
Penalty
Summary
The facility failed to obtain physician-ordered scheduled medications from the pharmacy for four residents, resulting in missed doses. The facility's policy requires that pharmaceutical services be available 24/7, ensuring residents have a sufficient supply of their prescribed medications. However, observations and interviews revealed that medications for residents were unavailable at the time of administration. For instance, a resident's Levothyroxine was not administered due to unavailability, and the LPN noted ongoing issues with the pharmacy in obtaining medications. Similarly, another resident's Spiriva inhaler was not available, preventing its administration as scheduled. The LPN expressed the need to reorder the medication, hoping for its arrival the next day. Additionally, a third resident missed multiple medications, including Metoprolol and Eliquis, due to unavailability. Lastly, a fourth resident's Furosemide was not administered as it was not available, necessitating a reorder from the pharmacy. These instances highlight the facility's failure to ensure timely access to necessary medications for its residents.
Failure to Provide Snacks and Complete Meals
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of its residents, as evidenced by the lack of snacks and incomplete meal services. Six residents reported not receiving snacks in the evening, despite being informed upon admission that they would have access to snacks of their choice. Additionally, residents expressed dissatisfaction with the meals served in their rooms due to COVID-19 restrictions, noting that they often did not receive beverages with their meals and were not provided with alternatives if they disliked the food served. The facility's dietary manager was unaware of these issues and mentioned that the variety of snacks had been reduced to simplify the process. Furthermore, the facility did not consistently provide fresh ice water to residents during each shift, as confirmed by the Director of Nursing. Residents reported receiving ice water infrequently, sometimes only once a day, despite the expectation that it should be provided more regularly. This lack of adherence to the facility's policies and resident preferences was documented in the Resident Council Minutes, where residents had previously raised concerns about not receiving fresh ice water regularly.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Medicare Advance Beneficiary Notice of Non-Coverage to two residents, identified as R232 and R329, out of a sample of 38 residents. According to the facility's document dated September 2022, residents should be informed in advance when changes occur to their bills, specifically when Medicare will not cover certain services. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) should be issued in situations of initiation, reduction, or termination of services when Medicare coverage is expected to end. Additionally, a Notice of Medicare Non-Coverage should be issued at least two days before the end of a Medicare-covered Part A stay. During an interview on August 28, 2024, the Accounts Receivable staff member, identified as V22, admitted to not having documentation of the SNFABN for residents R232 and R329. V22 was unable to confirm when or what these residents were informed regarding the termination of their Medicare A coverage. This lack of documentation and communication indicates a failure to comply with the required notification process, potentially leaving residents uninformed about their coverage status and financial responsibilities.
Failure to Conduct Required Level II PASRR Screenings
Penalty
Summary
The facility failed to obtain a Level II PASRR screening for two residents diagnosed with mental illness, which is a requirement under the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. If a Level I PASRR screen indicates a potential mental health condition, a Level II evaluation must be conducted by the state PASARR representative. However, for one resident, identified as R32, there was no evidence of a Level II PASRR screening being obtained after being diagnosed with Schizoaffective Disorder. The Director of Nursing confirmed that no PASRR Level II was requested for this resident. Similarly, another resident, identified as R34, had a Level I PASRR screen that indicated the need for a Level II evaluation due to diagnoses of Schizophrenia, Anxiety Disorder, and Depressive Disorder. Despite this indication, the medical record did not show evidence of a Level II PASRR screening being completed. The Director of Nursing acknowledged that the screening had not been done, and the Administrator-In-Training admitted uncertainty about when to request Level II PASRR assessments. These oversights highlight a failure to adhere to the facility's admission criteria policy and the PASRR process requirements.
Failure to Provide Therapy Services Leading to Resident's Functional Decline
Penalty
Summary
The facility failed to provide necessary therapy or restorative services to prevent a functional decline for a resident, identified as R46, who was reviewed for Activities of Daily Living (ADL) decline. According to the facility's policy, residents should receive care to maintain or improve their ADLs unless a clinical condition makes decline unavoidable. R46's care plan indicated a change from a sit-to-stand lift with two staff assistance to a non-weight bearing mechanical lift, yet no therapy or restorative services were provided to address this decline. The resident expressed a desire to receive therapy to regain strength and improve her ability to stand, but reported not receiving any physical therapy or exercises from the facility. The Director of Nursing and the Physical Therapist/Director of Rehab provided conflicting information regarding the resident's transfer status and therapy needs. The Physical Therapist noted that R46 was evaluated twice but was not picked up for therapy due to altered mental status and inability to follow cues. The therapist also mentioned that attending daily Interdisciplinary Team (IDT) meetings could have facilitated adding R46 to the therapy caseload, but was unable to attend due to productivity concerns. The resident's medical record lacked documentation of IDT meetings reviewing her functional decline or therapy needs, indicating a gap in the facility's care coordination and oversight.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident identified as R41. The facility did not perform weekly skin checks as required, with a missed assessment on 8-19-24. R41, who was moderately cognitively impaired and at moderate risk for pressure ulcers according to the Braden Scale, developed a Stage II pressure ulcer on the left buttock. Despite the identification of the ulcer, no treatment was administered until four days later, on 8-27-24. The resident's care plan indicated a need for frequent repositioning to prevent pressure ulcers, but this was not consistently implemented. Observations revealed that R41 was left sitting in a wheelchair for extended periods without repositioning, contrary to the care plan's instructions. Interviews with staff, including CNAs, indicated a lack of awareness regarding the repositioning orders for R41. The Director of Nursing acknowledged that the pressure ulcer was facility-acquired due to pressure and confirmed the lapse in weekly skin checks and delayed treatment application.
Failure to Implement ROM Services for Resident with Hemiplegia
Penalty
Summary
The facility failed to develop and implement services to maintain and/or improve range of motion (ROM) limitations for a resident diagnosed with hemiplegia following a cerebral infarction and muscle wasting. The resident, identified as R49, was observed to have functional limitations in the range of motion in one of the upper extremities and did not receive any passive or active ROM restorative programs or therapy. Despite being cognitively intact, the resident's current care plan did not address these limitations, and the resident reported not receiving any exercises from the staff. The facility's Restorative Nursing Services policy emphasizes individualized and resident-centered care to promote safety and independence, including maintaining or strengthening physical and psychological resources. However, the facility did not adhere to this policy for R49, as confirmed by the Restorative Aide, who stated that the resident was not on a restorative program to receive ROM exercises. This oversight indicates a failure to provide necessary restorative care to support the resident's physical health and independence.
Failure to Monitor Dialysis Access Site and Communicate with Dialysis Center
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident with End Stage Renal Disease (ESRD) who requires dialysis. The facility did not maintain ongoing communication with the dialysis center, monitor the dialysis access site, document observations post-dialysis, or implement a care plan for monitoring, care, and emergency management of the dialysis access site. The facility's policies require regular checks for infection and patency of the access site, documentation of post-dialysis observations, and communication with the dialysis center, none of which were followed for the resident in question. The resident, who attends hemodialysis at a local facility three times a week, reported that the facility staff never monitor her access site, leaving this responsibility to the dialysis staff. The facility's Director of Nursing confirmed the lack of communication with the dialysis center and the absence of documentation in the resident's medical record regarding the monitoring of the dialysis access site. Additionally, the resident's care plan did not include any interventions related to the monitoring or emergency care of the dialysis access site, indicating a significant oversight in the resident's care management.
Failure to Justify and Evaluate Antipsychotic Medication Use
Penalty
Summary
The facility failed to document targeted behaviors and diagnoses to justify the use of antipsychotic medications, perform antipsychotic evaluations and assessments, and perform gradual dose reductions of scheduled antipsychotic medications for two residents diagnosed with Dementia. The facility's policy requires that residents on psychotropic medications receive gradual dose reductions unless clinically contraindicated, and that non-pharmacological interventions be used to minimize the need for medications. However, for both residents reviewed, there was no documentation of targeted behaviors or evaluations to justify the continued use of antipsychotic medications. For one resident, the physician's orders documented the use of Quetiapine for Dementia with Delusional Disorder, with increases in dosage over time. Despite the increases, the resident's Minimum Data Set (MDS) assessments indicated no behaviors that would justify the use of such medication, and there was no documentation of interdisciplinary team meetings to discuss the necessity of the medication. Observations noted the resident was often sleeping, and staff reported the resident was easily redirected when exhibiting minor behaviors, such as yelling out. For the second resident, the physician's orders included Seroquel for Major Depressive Disorder and Dementia with other behavior disturbances. The MDS assessment showed no behavioral symptoms that would justify the use of antipsychotic medication. Staff interviews confirmed the absence of significant behaviors, and the resident's care plan lacked documentation of targeted behaviors or non-pharmacological interventions. The facility did not conduct antipsychotic drug assessments or evaluations, as required by their policy, to determine the appropriateness of the medication therapy.
Failure to Properly Explain Arbitration Agreement
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand. The arbitration agreement did not clearly state that it could be rescinded within 30 days of signing, nor did it require residents or their representatives to acknowledge their understanding of the agreement. This oversight had the potential to affect all residents residing in the facility. Interviews and record reviews revealed that the facility's marketing and admissions staff did not inform residents or their representatives that signing the arbitration agreement would waive their right to sue the facility. The staff member responsible for explaining the agreement instructed residents to read the options and decide which one to sign, without ensuring they understood the implications. During a Resident Council Meeting, several residents expressed that they were unaware of the arbitration agreement and did not know if they or their representatives had signed it. Additionally, a resident's Power of Attorney stated that she was not informed about waiving the right to litigation through the courts and would have preferred to know this information before choosing arbitration. The facility's contract did not include a provision for residents to rescind the arbitration agreement within 30 days, nor did it provide a section for residents or their representatives to acknowledge their understanding of the agreement. This lack of communication and documentation contributed to the deficiency identified by the surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) to prevent the spread of multi-drug resistant organisms (MDROs) among 16 residents reviewed for infection control. The facility's policy, dated August 2022, outlines the use of EBPs, including gown and glove use during high-contact resident care activities, for residents infected or colonized with specific MDROs or those with wounds and indwelling medical devices. Despite having a policy in place, the facility did not implement these precautions for residents with wounds, indwelling catheters, and a feeding tube. During an observation, certified nursing assistants and a registered nurse assisted a resident with perineal care and wound care without wearing gowns or using enhanced barrier precautions. Additionally, there was no signage or equipment indicating the need for EBPs near the resident's room. When questioned, the registered nurse was unaware of the enhanced barrier precautions, indicating a lack of training or communication regarding the policy. The facility administrator confirmed that the policy had not been implemented, and a list of residents requiring enhanced barriers had not been compiled.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a right heel unstageable pressure ulcer and suspected deep tissue injury. The resident's Physician Order Sheet (POS) required heel protectors to be worn at all times and specified a daily dressing change using a 0.25% sodium hypochlorite solution on moist gauze, followed by an abdominal pad and gauze wrap. However, during an observation, the resident's heels were not elevated with offloading boots or pillows, and the heel protectors were not in use. Additionally, the dressing on the resident's right heel was found to be soiled and dated six days prior, indicating it had not been changed daily as ordered. The Director of Nursing (V2) confirmed that the nursing staff had been peeling back and reusing the foam bordered gauze for six days, contrary to the manufacturer's instructions, which warned against reuse due to potential deterioration and cross-contamination. This practice was inconsistent with the physician's orders and the facility's wound care policy, which outlined specific steps for changing wound dressings, including daily changes. The failure to adhere to the prescribed treatment regimen and the facility's wound care policy resulted in inadequate care for the resident's pressure ulcer.
Failure to Safely Dispense Medications
Penalty
Summary
The facility failed to safely dispense medications to three residents (R2, R3, and R4) as observed by surveyors. For R2, the Licensed Practical Nurse (LPN) left the resident's 8:00 am medications on the bedside table without ensuring they were taken. The medications included Atenolol, Torsemide, Senna Lax, Aspirin, Carbidopa/Levadopa, Gabapentin, Acetaminophen, Losartan, Folic Acid, Cyanocobalamin, and Pantoprazole. The LPN admitted to leaving the medications for the resident to take after waking up and eating breakfast, acknowledging that this practice was inappropriate. Similarly, R3's 8:00 am medication, Polyethylene Glycol Powder, was left at the bedside by the same LPN, who did not stay to ensure the medication was taken. R3 stated they would take the medication after finishing breakfast. For R4, a medication cup containing multiple tablets and inhalers was left on the bedside table. R4 indicated they would take the medications after eating breakfast but was unsure of all the medications in the cup. The LPN confirmed the medications included Metoprolol, Eye Vitar, Vitamin C, Docusate Sodium, Multivitamin, and Citalopram, along with inhalers Symbicort and Spiriva. The Director of Nursing (DON) stated that nurses should not leave medications in residents' rooms without ensuring they are taken.
Failure to Timely Administer Medications
Penalty
Summary
The Facility failed to timely administer medications as ordered by the Physician for one resident (R3). The resident had multiple diagnoses including Sepsis, Cellulitis of Lower Limb, Pressure Ulcer Left Heel, Osteoarthritis, Diabetes Mellitus, Hypertension, Atrial Fibrillation, Transient Cerebral Ischemic Attack, Morbid Obesity, Bronchitis, and Chronic Kidney Disease. The Physician Order Sheet (POS) documented specific times for medication administration, including a 7:00 am dose of Humalog KwikPen sliding scale and various 8:00 am medications. However, on the observed date, the resident's breakfast tray was delivered at 9:13 am, and the resident completed the meal by 9:35 am. The Licensed Practical Nurse (LPN) administered the 7:00 am and 8:00 am medications at 9:35 am, which was after the scheduled times and after the resident had finished breakfast. The LPN acknowledged that the resident received medications, including insulin, after the scheduled times and after the meal. The Director of Nursing (DON) confirmed that medications, especially insulin, should be administered at their scheduled times and not after meals. This delay in medication administration constitutes a significant medication error, as it did not adhere to the physician's orders and the facility's medication administration policy, potentially compromising the resident's health and safety.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Quincy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blessing Hospital Snu | 1.6 mi | ★★★★★ | 0 | 0 |
| Sunset Home | 1.9 mi | ★★★★★ | 4 | 2 |
| Good Samaritan Home | 2.6 mi | ★★★★★ | 1 | 0 |
| Maple Lawn Nursing Home | 13.3 mi | ★★★★★ | 23 | 0 |
| Luther Manor Retirement & Nursing Center | 14.7 mi | ★★★★★ | 36 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.