Quincy Retirement Community

Based on clinical record review and staff interview, it was determined the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman for one of one residents reviewed for hospitalization (Resident 55).Findings Include: Review of Resident 55's clinical record revealed diagnoses that included metabolic encephalopathy (acute brain dysfunction caused by systemic illness) and sequelae of cerebral infarction (physical, cognitive, and psychological disabilities resulting from brain tissue damage). Further review of Resident 55's clinical record revealed that on December 26, 2025, and January 1, 2026, Resident 55 was transferred out of the facility to the hospital and was subsequently admitted to the hospital. Review of the facility's Ombudsman transfer/discharge reporting documentation for the months of December 2025 and January 2026 revealed that Resident 55 was not on the list for either month. During an interview on February 25, 2026, at 12:09 PM, with the Nursing Home Administrator (NHA), it was confirmed that Resident 55 was not on the list for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 59).Findings include: Review of facility policy, titled Wound Care, dated December 29, 2025, revealed, in part, Health Center Registered nurse will assess, document, and notify the physician of a new pressure injury no later than the end of the following shift from the time the wound is found. Consult the dietician for all residents at risk for or with skin breakdown or wounds. Nutritional goals should be established. In addition, the policy indicated black heels that are intact and without signs and symptoms of infection or fluctuation are treated with pressure redistribution. No dressing is necessary. Float heels. May apply protective barrier twice a day and as needed. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure alleged violations involving abuse were investigated thoroughly and reported in a timely manner for one resident reviewed for abuse allegation (Residents 1).Findings include: Review of facility policy, titled Abuse, Neglect, Exploitation last reviewed December 25, 2025, revealed Under the Elder Justice Act, an individual must report any reasonable suspicion of a crime against a resident or participant within 2 hours of the reasonable suspicion if the incident involves serious bodily injury and within 24 hours if the incident does not involve serious bodily injury. The facility policy added a section, titled Identification of Abuse, that stated:All bruises, skin tears and other found injuries are investigated for potential abuse.Event and Response Reports are reviewed by physician, Director of Nursing, MedicalDirector, and Administrator for further action.Review of the facility incident dated December 24, 2025, at 9:00 PM, stated NA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that residents' medical records were complete and accurately documented for one of 18 residents reviewed (Resident 5). Findings include: Review of Resident 5's clinical record revealed diagnoses that included fracture of the left ulna (break of the bone in the forearm) and anxiety disorder (excessive and persistent worrying). Review of Resident 5's January TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed the following order was not documented as being completed on the dates noted: splint - three times a day, ensure left arm splint on left arm at all times; not documented day shift January 28 and 29, 2025; evening shift January 25, 30, and 31, 2025; and night shift January 23, 24, and 31, 2025, and February 5, 2025. During an interview with Resident 5 on February 4, 2025 at 10:41 AM, it was revealed she wears the brace at all times since having her cast removed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 21 residents reviewed (Residents 1, 13, and 64). Findings include: Review of Resident 1's November 2024 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an ongoing order for Olanzapine (antipsychotic medication) twice daily, effective September 14, 2024. Review of Resident 1's December 26, 2024, quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that this assessment was not coded to indicate that she had received antipsychotic medications since admission/entry, reentry, or the prior OBRA assessment (Omnibus Budget Reconciliation Act - set federal standards for nursing home care), whichever was more recent. Review of Resident 1's MDS assessment completion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, it was determined that the facility failed to develop a comprehensive care plan that included a history of urinary tract infections (UTI's) for one of 21 records reviewed (Resident 43). Findings include: A review of the clinical record for Resident 43 revealed diagnoses that included history of UTI's and Non-Alzheimer's Dementia (a group of cognitive disorders that cause memory loss, confusion, and other symptoms observed with Alzheimer's disease but have different underlying causes). A review of the clinical record for Resident 43 revealed admission to the facility on September 13, 2024. Resident 43 was admitted with a diagnoses of UTI. Resident 43 was ordered Macrobid (antibiotic) 100 mg (milligram) for 10 days. The clinical record also revealed that Resident 43 had a UTI on February 9, 2024. Resident 43's Urologist (a doctor who specializes in the urinary tract system) ordered Nitrofurantoin MCR (antibiotic) 50 mg capsule by mouth daily as a preventive measure due to a history of UTI's. A review of Resident 43's care plan failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interview, it was determined that the resident care plan was not reviewed and revised to reflect the resident's current status for one of 21 residents reviewed (Resident 10). Findings include: Review of Resident 10's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream) and stage 3 chronic kidney disease (moderate loss of kidney function). Review of Resident 10's active care plan on February 4, 2024, at 1:00 PM, revealed that she was careplanned for having an indwelling catheter (device inserted into the bladder for drainage). Review of hospital notes dated October 26, 2024, revealed that Resident 10's foley catheter was removed on that date. Observation of Resident 10 on February 4, 2025, at 9:37 AM, failed to reveal the presence of a catheter. Review of Resident 10's February 2025 MAR and TAR (Medication and Treatment Records) failed to reveal any orders for an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for five of 18 residents reviewed (Residents 8, 19, 49, 56, and 76). Findings include: Review of Resident 8's clinical record revealed diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Further review of Resident 8's clinical record revealed their admission progress note dated January 2, 2024, which indicated the presence of an unstageable deep tissue injury. Review of Resident 8's Comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 8, 19, and 56). Findings include: Review of facility policy, titled Care Planning, with a last review date of December 7, 2023, revealed, in part: Presbyterian Senior Living will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by our Mission Statement as well as State and Federal guidelines . 10. The care plan will be updated electronically as needed; and 11. The care plan will be reviewed and evaluated for intervention effectiveness no less than quarterly. Review of Resident 8's clinical record revealed diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and diabetes mellitus type II (disease that occurs when your blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 18 residents reviewed (Resident 19). Findings include: Review of facility policy, titled Wound Care, with a last approved date of December 12, 2023, revealed, in part: Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and symptom control as appropriate. Review of Resident 19's clinical record revealed diagnoses that included diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high), ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility policy review, and review of facility legionella guidelines, it was determined the facility failed to implement a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia)); and failed to maintain accurate infection control data. Findings include: A review of the facility policy, titled Anticipated Increase in Legionellosis Cases Due to Seasonality, dated June 12, 2023, failed to address any baseline or annual testing in the facility for water-borne contaminants, such as Legionella. A review of the facility policy, titled Surveillance for Health-Care Associated Infections (HAI), last reviewed February 22, 2024, stated, The purpose of the surveillance of infections is to identify both individual cases and trends in the transmission of epidemiologically significant organisms and Healthcare-Associated Infections, to permit interventions to try…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident's physician's discharge summary included all required documentation for two of three residents reviewed for discharge (Residents 83 and 85). Findings include: Review of facility policy, titled Physician Services, with a last approved date of [DATE], revealed 13. The physician, CRNP [Certified Registered Nurse Practitioner], or PA [Physician Assistant] must complete a Discharge Summary that includes a recapitulation of the resident stay and pertinent instructions for continuity of care upon discharge. Review of Resident 83's clinical record on [DATE], at approximately 10:00 AM, revealed Resident 83 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements) and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services for urinary catheters consistent with the resident's comprehensive plan of care for one of six residents reviewed for urinary catheters (Resident 63). Findings include: Review of Resident 63's clinical record on March 4, 2024, at approximately 1:00 PM, revealed diagnoses that included chronic kidney disease (CKD - decreased ability of the kidneys to filter toxin from the blood and produce urine) and osteomyelitis (infection of the bone) with sepsis (life threatening condition that results in dysfunction of the immune system entering the blood stream and causing inflammation in organs through out the body). Review of Resident 63's clinical record revealed Resident 63 utilized a urostomy (surgical opening to the bladder through the skin) with a catheter for urine elimination. Review of Resident 63's comprehensive plan of care revealed that Resident 63 had a care plan with the identified problem of, [Resident 63] has an ostomy to divert urine [related to]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of six residents reviewed for unnecessary medications (Resident 61). Findings include: Review of facility policy, titled Management of Behavioral or Psychological Symptoms of Dementia-BPSD with or without Antipsychotic, with a last approved date of December 22, 2023, revealed the following, in part: The FDA [Food and Drug Administration] Black Box Warning Regarding Atypical & Conventional Antipsychotic in Dementia states, 'Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo; Residents/families/representatives should be involved in discussions about potential approaches to address behaviors and about the potential risks and benefits of a psychopharmacological medication (e.g., FDA black box warnings), the proposed course of treatment, expected duration of use of the medication, use of individualized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.