Quince Nursing and Rehabilitation Center

Based on job description review and interview, the facility failed to have a Register Dietitian (RD) or other clinically qualified nutrition professional for 153 of 153 residents residing in the facility. The findings include: 1. Review of the job description titled Registered Dietitian, dated 3/4/2026, revealed .Job Summary.Coordinates nutritional care of residents by completing nutritional assessments, developing and implementing care plans and documenting dietary information about residents. Provides guidance and collaborates with the Dietary Manager in the provision of food and nutrition services.Nutritional Care Responsibilities.Ensures physicians orders are followed making recommendations for changes needed.Completes nutritional assessments, MDS [Minimum Data Set], CAA [Care Area Assessment] and care plans.Provides routine and change of condition progress notes in the residents' medical record .determines the effectiveness of nutritional care plan; documents outcome in the progress notes and adjusts care plans as needed .Reviews weight records routinely and communicates…

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 policy review, medical record review, and interview the facility failed to ensure timely notice regarding Medicare eligibility and coverage for 1of 3 (Resident #76) sampled residents. The findings include: Review of the undated facility policy titled, Advanced Beneficiary Notice (ABN), revealed .It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.A Notice of Medicare Non-Coverage (NOMNC), Form CMS [Centers for Medicare and Medicaid] -10123, shall be issued to the resident/representative when Medicare Part A covered service (s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO).the notice shall be provided within forty-eight hours of the last anticipated covered day. Review of the medical record reveal Resident #76 was admitted to the facility on [DATE] with diagnoses including…

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 policy review, Director of Nursing (DON) job description review, Registered Dietitian (RD) job description review, medical record review, observation, and interview, the facility failed to assess for and ensure residents maintained acceptable parameters of nutritional status for 1 of 4 ( #173) sampled residents reviewed for nutrition. The findings include: 1. Review of the facility's policy titled, Weight Assessment and Intervention, dated 10/5/2025, revealed .The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Significant unplanned and undesired weight changes will be based on the following criteria [where percentage of body weight loss = (usual weight-actual weight) / (usual weight) x 100] .1 month- 5% [percent] weight change is significant; greater than 5% is severe .3 months- 7.5% weight change is significant; greater than 7.5% is severe .6 months- 10% weight change is significant; greater than 10% is severe.Weights will be…

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 policy review, job description review, orientation checklists, record review, and interview, the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to detect changes in a resident's condition, perform neurological assessments, and monitor a resident after a change in condition for 1 of 5 (Residents #3) sampled residents. The findings include: 1. Review of the undated facility policy titled, Neurological Evaluations, revealed .It is the policy of this facility to perform a neuro [neurological] vital sign evaluation when indicated by resident condition.Perform neurological checks.and document on the Neurological Evaluation Flow Sheet.Determine state of consciousness.Check all three spheres (person, place , time) and observe speech pattern.Take temperature, pulse, respirations and blood pressure.Check pupil reaction. Darken room. Open eyelid with your fingertips. Turn on flashlight and observe size and reaction of pupil. Repeat for the other eye. Determine motor…

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, observation, and interview, the facility failed to ensure 9 of 22 staff (Licensed Practical Nurse (LPN) #4, #5, Certified Nursing Assistant (CNA) #1, #2, #3, #5, #6, #7, and #11) provided care for a resident in a manner that maintained or enhanced the resident's dignity when the staff did not knock on resident doors prior to entering the room, called residents feeders, and did not address the resident by a courtesy title for 13 of 133 residents (Resident #8, #9, #17, #20, #37, #40, #43, #49, #64, #112, #122, #341 and #342) observed during dining. The findings include: Review of the facility's policy titled, RESIDENT BILL OF RIGHTS, revised on 11/2017, revealed .Each resident has a right to a dignified existence .communication .in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . Dining observation in the resident's room on 10/17/2021 at 12:45 PM, revealed LPN #4 entered Resident #37's room without knocking or requesting permission to enter the resident's room. Dining observation in in the residents'…

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 policy review, medical record review, observation, and interview, the facility failed to provide the necessary respiratory care and services when oxygen tubing was not dated and/or changed weekly for 5 of 6 sampled residents (Resident #62, #63, #101, #123, and #190) reviewed for oxygen therapy. The findings include: Review of the facility's undated policy titled, Oxygen [O2] Therapy, revealed, .Humidifier if needed .change tubing weekly .Date tube when changed (weekly) . Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of Fracture of Neck of Right Femur, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, and Hypertensive Heart Disease. Review of the Physician Order dated 9/8/2021, revealed .Oxygen @ [at] 2L [liter]/min [per minute] bnc [bi-nasal cannula]. Titrate [measure and adjust to the needs of the resident] to keep O2 [oxygen] sat [saturation] >/= [greater than or equal to] 92% [percent] . Observation in the resident's room during…

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, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when undated, open medications and expired medications were observed in 1 of 11 medication storage areas (West Hall Medication Room) and when 1 of 5 nurses (Licensed Practical Nurse (LPN) #2) left medications unattended for 1 of 6 sampled residents (Resident # 343) observed during medication pass. The findings include: Review of the facility's policy titled, Medication Storage, dated 11/2010, revealed .Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications .All drugs, treatments, and biologicals must be stored securely . Review of the facility's undated policy titled, Medication Administration - General Guidelines, revealed .During routine administration of medications .No medications are left unattended . Observation of the [NAME] Hall Medication Room on 10/17/2021 at 12:40 PM, revealed a locked refrigerator containing: 1 open, undated, multidose vial of tuberculin 7…

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 document review and interview, the facility failed to document the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care on every shift on the staffing postings and failed to have staffing postings completed and available for 24 of 76 days of staffing postings (12/2/2019, 12/3/2019, 12/4/2019, 12/5/2019, 12/6/2019, 12/7/2019, 12/8/2019, 12/9/2019, 12/12/2019, 12/14/2019, 12/15/2019, 12/25/2019, 1/7/2020, 1/8/2020, 2/1/2020, 2/2/2020, 2/3/2020, 2/4/2020, 2/10/2020, 2/11/2020, 2/12/2020, 2/13/2020, 2/14/2020, and 2/17/2020) reviewed. The findings include: Review of the staffing postings between 12/1/19 and 2/18/2020, showed the facility did not document actual Registered Nurse hours worked on 12/2/2019, 12/3/2019, 12/4/2019, 12/6/2019, 12/7/2019, 12/8/2019, 12/25/2019, 1/7/2020, 1/8/2020, 2/3/2020, 2/4/2020, 2/11/2020, 2/12/2020, 2/13/2020, 2/14/2020, and 2/17/2020. Review of the staffing postings between 12/1/2019 and 2/18/2020, showed the facility did not document actual Licensed Practical Nurse and Certified…

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, medical record review, observation, and interview, the facility failed to ensure residents who received psychotropic medications were appropriately monitored for side effects and behaviors for 5 of 7 sampled residents (Resident #27, #100, #104, #111, and #283) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled, SUBJECT: Behavior Management and Psycho-pharmological Medication Monitoring Protocol, dated 3/2018, showed that medication side effects and resident behaviors should be monitored for residents receiving antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety (psychotropic) medications. 1. Review of the medical record showed, Resident #27 had a diagnosis of Cerebral Infarction, Diabetes Mellitus, End Stage Renal Disease and Dependent on Renal Dialysis, Insomnia, and Psychosis. Review of the Physician Orders dated 1/16/2020, showed, .SERTRALINE HCL [Hydrochloride] [an antidepressant] 100 MG [milligrams] .TWO .TABLETS .BY MOUTH EVERY EVENING . Review of the December 2019, January 2020, 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 policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed in 2 of 3 isolation rooms (Resident #107 and #163) and failed to maintain infection control practices when 2 of 6 nurses (Licensed Practical Nurse [LPN] #3 and #4) failed to perform proper hand hygiene, failed to clean a stethoscope, and failed to protect the feeding tube tip from being contaminated for 2 of 7 sampled residents (Resident #45 and #88) reviewed during medication administration observations. The findings include: Review of the facility's policy titled, .CONTACT PRECAUTIONS, dated 9/2019, showed that a door sign that reads Contact Precautions or Visitors Must See Nurse Before Entering must be on the door, a cart must be placed outside the room that contains a covered supply of personal protective equipment such as gowns, gloves, masks, and plastic bags, and personal protective equipment should be worn prior to entering the room. 1. Review of the medical record showed, Resident #107 had diagnoses 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 review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility to complete and transmit an MDS assessment within 14 days of the completion date for 1 of 38 sampled residents (Resident #2) reviewed for Resident Assessment and transmission. The finding include: Review of the MDS 3.0 RAI Manual v (version) 1.16 October 1, 2018 page 664, showed, .Assessment Transmission .MDS assessments must be submitted within 14 days of the MDS Completion Date . Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with diagnoses of Hypothyroidism, Diabetes Mellitus, Osteoarthritis and Malignant Neoplasm of Bladder. Review of the annual MDS assessment, showed the assessment had an Assessment Reference Date of 1/10/2020 and a completion date of 1/24/2020. The annual assessment should have been transmitted by 2/7/2020, but had not been transmitted. During an interview conducted on 2/20/2020 at 6:55 PM, MDS Coordinator…

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 medical record review, observation, and interview, the facility failed to accurately assess residents for bladder and bowel continence, activities of daily living, cognition, and the use of antipsychotics for 4 of 38 sampled residents (Resident #10, #62, #87, and #104) reviewed. The findings include: 1. Review of the medical record, showed Resident #10 had diagnoses of Cerebral Infarction, Dysphasia, Schizoaffective Disorder, Diabetes Mellitus, and Hypothyroidism. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #10 was frequently incontinent of bladder and bowel. Review of the annual MDS dated [DATE], showed Resident #10 was always incontinent of bladder and bowel. Review of the Care Plan dated 11/25/2019, showed, .[Named Resident #10] is incontinent of bowel and bladder r/t [related to] impaired mobility and cognitive deficit . During an interview conducted on 2/20/2020 at 2:13 PM, MDS Coordinator #2 confirmed the MDS dated [DATE] was coded incorrectly for bladder 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 medical record review, observation, and interview, the facility failed to implement fall interventions for 2 of 5 sampled residents (Resident #71 and #135) reviewed for falls. The findings include: 1. Review of the medical record, showed Resident #71 had diagnoses of Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Coronary Artery Disease, and Diabetes. Review of the Care Plan revised 1/15/2020, showed, .Problem .has the potential for falls and fall related injuries r/t [related to] poor safety awareness .Approaches .1/15/20 [2020] .dycem [cushion that prevents sliding] to w/c [wheelchair] . Observation in the resident's room on 2/20/2020 at 3:50 PM, showed there was no dycem in Resident #71's wheelchair. During an interview conducted on 2/20/2020 at 3:50 PM, Licensed Practical Nurse (LPN) #1 confirmed there was no dycem in Resident #71's wheelchair. 2. Review of the medical record, showed Resident #71 had diagnoses of Diabetes, Dementia, and Legal Blindness. Review of the Care Plan revised 12/14/2019, showed, .Problem .is at risk for falls .Approaches…

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 medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 1 of 2 sampled residents (Resident #103) reviewed for the use of an indwelling urinary catheters. The findings include: Review of the medical record, showed Resident #103 had diagnoses of Congestive Heart Failure, Hemiplegia, and Benign Prostatic Hyperplasia. Review of the February 2020 Physician Orders, showed, .MAINTAIN PATENCY AND PLACEMENT OF #18FR [FRENCH] / 10CC [CUBIC CENTIMETERS] BULB INDWELLING FOLEY CATHETER EVERY SHIFT .FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT . Review of the February 2020 Medication Administration Record (MAR), showed no documentation to maintain placement and patency of an indwelling urinary catheter from 2/9/2020 through 2/20/2020 for the 7:00 AM to 7:00 PM shift and no documentation on 2/12/2020, 2/13/2020, 2/14/2020, 2/16/2020, 2/17/2020, and 2/19/2020 for the 7:00 PM to 7:00 AM shift. Review of the February 2020 MAR, showed no documentation for catheter care for an indwelling urinary…

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.