Quadrangle Personal Care.

“Staff members prevented a resident from freely associating with another resident by asking them to leave the resident's room on multiple occasions (at approximately 9:30 PM and 11:30 PM). The Administrator instructed staff to keep the residents separated, violating the resident's right to freely associate and communicate with others privately.”

“A resident participated in the development of their support plans but did not sign the support plans, in violation of the requirement that individuals who participate in the development of the support plan shall sign and date it. This is a repeat violation.”

“The administrator provided a partial contact list that did not include ancillary staff members.”

“On the inspection date from 11 am to 7 pm, 101 residents were present but only 2 staff persons were certified in CPR and only 1 person was certified in first aid and obstructed airway techniques. The requirement is at least one staff person for every 50 residents trained in these areas.”

“At 9:14 am on the inspection date, there was approximately 3 inches of snow accumulation on several walkways including outside the main dining room exit, near the salon, and memory care exits and courtyard, which had not been removed.”

“Egress doors from the main dining room, the door closest to the salon, the exit from stairwell 4, and both exits from the memory care dining area were unable to be opened because 3 inches of snow and ice accumulation prevented the doors from opening.”

“A resident's most recent medical evaluation was not completed within the required annual timeframe.”

“The weekly menu was not fully posted for the applicable week, and the menu was posted only at the front of the building in a non-conspicuous location, making it inaccessible to residents in the secured dementia care unit.”

“A resident's current assessment was not completed within the required annual timeframe.”

“A resident's record does not include a copy of the official death certificate, which is required to be maintained in the resident's file.”

“There was no thermometer in the refrigerator and freezer in the 1st floor activity room. Food requiring refrigeration must be stored at or below 40°F and frozen food at or below 0°F, with thermometers required in both units.”

“Food was not stored in closed or sealed containers. Cakes and pies in the reach-in refrigerator were opened and unsealed, whipped cream in the secured dementia care unit refrigerator was opened and unsealed, and ice cream in the secured dementia care unit freezer was opened and unsealed.”

“Outdated or spoiled food was available for use. An unlabeled, undated bottle of Wishbone Italian salad dressing and peanut butter were found in the secured dementia care unit freezer.”

“Training documentation for direct care staff annual training was incomplete or not provided in full during inspection.”

“Facility had 98 residents including 26 with mobility needs requiring minimum 124 hours of direct care service but only provided 121.5 hours.”

“Resident requiring assistance with dressing per assessment and support plan was observed in hospital gown without receiving required assistance.”

“Resident-home contract was not signed by the home as required.”

“Multiple incidents of potential abuse and neglect in secured dementia care unit: resident bit another resident causing bleeding injury while staff were not adequately supervising; another incident where a resident was left unattended in a sit-to-stand device for approximately 5 minutes despite not being assessed for use of that device and having mobility limitations requiring one-person assistance.”

“On two dates, the facility failed to provide the required 75% of direct care service hours during waking hours. First date required 92.25 hours but only 91 provided during waking hours; second date required 94.5 hours but only 93 provided during waking hours.”

“Administrator did not maintain a current, accurate staff list. List provided was incorrect and included terminated staff while omitting active maintenance personnel.”

“Facility failed to maintain required staffing of at least one CPR-certified staff person per 50 residents on multiple shifts: one shift with 100 residents had only 1 certified person; two shifts had 0 CPR-certified staff present while 98-100 residents were in the home.”

“A staff member made a resident's bed without a top sheet. When the resident requested one, the staff member retrieved it but threw it on the bed and left without properly assisting, saying the resident hadn't asked for it to be put on. The resident felt disrespected and uncomfortable by the interaction.”

“The home could not provide a policy or procedure indicating reasonable call bell response times. Documentation showed response times indicating the home was not adequately staffed to meet residents' needs as specified in their assessments and support plans.”

“Direct care staff member A, hired and beginning work in April 2023, provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.”

“Direct care staff member A did not receive required annual training in 2024, including medication self-administration training, instruction on meeting resident needs per assessment and support plan, safe management techniques, and care for residents with mental illness or intellectual disability.”