Park Manor of Quail Valley

In the surveyor’s words

From the most serious findings on record at Park Manor of Quail Valley, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 24, 2025

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 32 residents (Resident #93 and Resident #13) reviewed for adequate supervision. - The facility failed to ensure Resident #93 who was on continuous oxygen did not smoke while oxygen was being administered from 03/20/25 through 06/03/25. The facility documented they found cigarettes and a lighter in Resident #93's room on 03/22/25 and was observed smoking while on oxygen in front of the facility on 4/18/25 and 06/03/25. -The facility failed to ensure Resident #13 bed rail/assistance bar was attached to the bed securely. […]

• No harm, potential for more than minimal, widespreadF804Feb 16, 2023

  Based on observation, interview and record review, the facility failed to ensure each resident receives and the facility provides food that is palatable and at an appetizing temperature for 7 of 21 residents reviewed for food and nutrition dietary services (Resident #32, #50, #52, #53, #55, #79, #88), in that: ---(11) residents in a confidential group interview said the food was cold and not palatable when it was served ---residents said food was cold and not palatable when it was served and had no flavor This failure placed residents who ate meals in the dining room and in their rooms at risk of diminished quality of life and weight loss due to decreased food quality and temperature. […]

• No harm, potential for more than minimal, patternF755Feb 2, 2024

  Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one (Closed Record #1) reviewed for pharmacy services. 1. Unit Manager A failed to transcribe physician orders to administer Atorvastatin Calcium Oral Tablet 40 MG at bedtime for CR #1. These failures placed CR #1 at risk of not receiving full dosage and treatment of medication as ordered. Findings Include: Record review of CR #1's facility face sheet dated 12/1/2023 revealed a [AGE] year-old female with an initial admitted [DATE] and re-admitted [DATE]. […]

• No harm, potential for more than minimal, patternF760Feb 2, 2024

  Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 resident CR #1) reviewed for medication errors in that: 1. The facility failed to ensure Unit Manager transcribed physician orders to administer Atorvastatin Calcium Oral Tablet 40 MG at bedtime for CR # These failures placed residents at risk of not receiving treatment of medication as ordered to treat medical diagnoses. Record review of the Medication Error Report dated 7/7/2023 read in part .Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day related to other Hyperlipidemia was d/c'd in error for CR #1;orders to run lab. Lipid panel lab results were returned and within normal ranges. NP notified . […]

• No harm, potential for more than minimal, isolatedF550Jun 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 residents (Resident #355) reviewed for privacy, in that: - The facility failed to place Resident #355's foley catheter bag inside of a privacy bag on 06/03/2025. These failures placed residents at risk for embarrassment, at risk of loss of dignity and decrease in quality of life. The findings include: Record of Resident #355's Facesheet dated 06/05/2025 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but were not limited to benign prostatic hyperplasia (gland enlargement) without lower urinary tract symptoms, sepsis (a life-threatening complication of an infection, and… […]