QUINCY HEALTH AND REHABILITATION CENTER LLC

Nursing Home Inspector

11 MCGRATH HIGHWAY
QUINCY, MA 02169
Norfolk County
Phone: 617-479-2820
Provider Number: 225263
Last Inspection: 09/14/2016

About the Nursing Home

Number of Beds: 126
Number of Residents: 113
Beds Available: 13
Percent Occupancy: 90%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

95

Facility
20

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

95

2016
58

2015
3

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 11/24/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 11/24/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 12/10/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 11/24/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 11/24/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 12/10/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Actual 4 12/10/2016
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 11/24/2016
 
Failed To: Have enough outside ventilation via a window or mechanical ventilation, or both. Widespread : Minimal 5 11/24/2016
 
Failed To: Quickly tell the resident's doctor the results of laboratory tests. Isolated : Minimal 3 11/24/2016
 
Failed To: Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. Isolated : Minimal 3 11/24/2016
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 11/24/2016
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated : Actual 4 12/10/2016
 
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 12/10/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 11/24/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 11/24/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 12/10/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 12/10/2016
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Isolated : Minimal 3 11/24/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 11/24/2016
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 11/24/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 11/24/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 11/24/2016
 
Failed To: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Isolated : Minimal 3 11/24/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 12/10/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 11/24/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/10/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 11/24/2016
 

5/19/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 8/28/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 8/28/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 8/28/2015
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 8/28/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 8/28/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 8/28/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 8/28/2015
 
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Isolated : Actual 4 8/28/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 7/3/2015
 
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 7/3/2015
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 7/3/2015
 
Failed To: Tell the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Isolated : Minimal 3 8/28/2015
 
Failed To: Provide residents with private access to a telephone. Pattern : Minimal 4 7/3/2015
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Actual 4 7/3/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 8/28/2015
 
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 8/28/2015
 

3/31/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 4/30/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

1/12/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. Isolated : Minimal 3 3/4/2016
 
Failed To: Provide care for each resident in a way that maintains or improves their quality of life. Pattern : Minimal 4 3/4/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 3/4/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 3/4/2016
 

10/22/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 12/14/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 113 95.41 96.79
Registered Nurses 0.81 1.00 0.89
Licensed Practical / Vocational Nurses 1.02 0.70 0.84
Certified Nursing Assistants 1.96 2.41 2.30
Total Staff Hours 3.79 4.11 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 7 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 39 90 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 85 95 95
of long-stay residents experiencing one or more falls with major injury 5 4 3
of long-stay residents who have depressive symptoms 1 2 2
of long-stay residents who lose too much weight 8 5 5
of long-stay residents who received an antianxiety or hypnotic medication 17 17 20
of long-stay residents who received an antipsychotic medication 17 17 18
of long-stay residents who self-report moderate to severe pain 1 3 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 10 19 18
of long-stay residents whose need for help with daily activities has increased 5 16 14
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 0 3 3
of low risk long-stay residents who lose control of their bowels or bladder 32 53 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 47 74 79
of short-stay residents who had an outpatient emergency department visit 15 11 11
of short-stay residents who made improvements in function 35 60 60
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 12 13 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 47 81 82
of short-stay residents who were rehospitalized after a nursing home admission 35 24 22
of short-stay residents who were successfully discharged to the community 40 55 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0