Inspection Reports for Bear Creek Care and Rehabilitation Center
150 Spring St, Morrison, CO 80465, Morrison, CO, 80465
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 4, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident sexual abuse and harassment, as well as concerns about adequate supervision and staff training.
Complaint Details
The complaint investigation substantiated sexual abuse of Resident #7 by Resident #8 on 9/29/25, sexual harassment of Resident #3 and Resident #5 by Resident #4, and inadequate supervision leading to elopement of Resident #2 on 8/12/25. The facility failed to implement effective interventions and staff education to prevent these incidents.
Findings
The facility failed to protect residents from sexual abuse and harassment by other residents, resulting in immediate jeopardy to resident health and safety. The facility also failed to provide adequate supervision to prevent elopement and failed to maintain an effective staff training program.
Deficiencies (3)
Failure to protect residents from sexual abuse and harassment by other residents, including failure to implement effective interventions and supervision.
Failure to ensure adequate supervision to prevent accidents, including elopement of a resident resulting in injury.
Failure to develop, implement, and maintain an effective training program for staff, including dementia, behavioral health, infection control, resident rights, communication, and quality assurance training.
Report Facts
Residents reviewed for abuse: 10
Residents affected by sexual abuse or harassment: 4
Date of sexual abuse incident: Sep 29, 2025
Date of elopement incident: Aug 12, 2025
Number of deficiencies cited: 3
BIMS score: 9
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Failed to notify staff or implement interventions after Resident #2 stated he was not staying at the facility |
| CNA #1 | Certified Nurse Aide | Unaware of door tags and education binder related to abuse prevention |
| LPN #4 | Licensed Practical Nurse | Unaware of door tags and education binder related to abuse prevention |
| Staff Development Coordinator | Staff Development Coordinator | Provided education but facility had gaps in staff training documentation |
| Nursing Home Administrator | Nursing Home Administrator | New administrator aware of gaps in staff education and working to improve training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 28, 2025
Visit Reason
The inspection was conducted due to complaints regarding resident-to-resident verbal and physical abuse and concerns about medication errors at the facility.
Complaint Details
The complaint investigation focused on allegations that Resident #5 verbally and physically abused other residents, causing fear and distress. The facility failed to implement a consistent one-to-one caregiver as recommended. Additionally, a medication error was identified where Resident #1 missed multiple doses of IV vancomycin due to pharmacy and communication failures.
Findings
The facility failed to protect residents from verbal and physical abuse by another resident with aggressive behaviors, and failed to ensure residents were free from significant medication errors, including missed doses of IV vancomycin for one resident.
Deficiencies (2)
Failure to protect residents from verbal and physical abuse by Resident #5, who exhibited aggressive behaviors including yelling, screaming, and physical threats.
Failure to ensure residents were free from significant medication errors, specifically Resident #1 did not receive ordered IV vancomycin doses.
Report Facts
Residents reviewed for abuse: 27
Residents affected by abuse: 2
Residents reviewed for medication errors: 27
Residents affected by medication errors: 1
Invoice amount: 4200
One-to-one sitter hours: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Attempted to redirect Resident #5 during aggressive episodes |
| ADON | Assistant Director of Nursing | Notified about missed medication doses and pharmacy issues for Resident #1 |
| NHA | Nursing Home Administrator | Provided facility policy and discussed billing and care issues related to Resident #5 |
| DON | Director of Nursing | Disapproved admission of Resident #5 and commented on admission process |
| SSD | Social Services Director | Provided one-to-one care intermittently for Resident #5 and commented on admission process |
| CNC | Clinical Nurse Consultant | Commented on admission process and facility plan to prevent future incidents |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 9, 2025
Visit Reason
The inspection was conducted due to complaints and incidents involving inadequate supervision and failure to implement assistive devices and interventions to prevent accidents, resulting in injuries to three residents (#1, #8, and #9).
Complaint Details
The investigation was complaint-driven, focusing on incidents involving Residents #1, #8, and #9 where inadequate supervision and failure to follow care plans led to serious injuries. The complaint was substantiated with findings of actual harm.
Findings
The facility failed to ensure proper supervision and adherence to care plans for residents requiring assistive devices and safety interventions, leading to multiple falls and injuries including fractures and skin tears. Despite implementing plans of correction after initial incidents, the facility did not effectively address accident hazards, resulting in further resident injuries.
Deficiencies (3)
Failure to use a hoyer lift for transfers as ordered, resulting in a fractured left ankle for Resident #1.
Failure to place a fall mat next to Resident #8's bed, leading to a fall with multiple fractures and skin injuries.
Failure to prevent Resident #9 from leaving the facility unsupervised due to deactivated door alarm, resulting in multiple fractures and head injury.
Report Facts
Residents reviewed: 10
Sample residents: 12
Residents affected: 3
Date of survey completed: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Named in failure to place fall mat for Resident #8 leading to fall |
| CNA #1 | Certified Nurse Aide | Interviewed regarding transfer of Resident #1 without hoyer lift |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding transfer of Resident #1 without hoyer lift |
| Assistant Director of Nursing | ADON | Interviewed about staff not using hoyer lift for Resident #1 |
| Director of Nursing | DON | Conducted investigations and interviews related to all three residents' incidents |
| Interim Nursing Home Administrator | INHA | Provided facility policy and interviewed regarding incidents and investigations |
| LPN #2 | Licensed Practical Nurse | Interviewed about fall mat placement for Resident #8 |
| CNA #2 | Certified Nurse Aide | Interviewed about fall mat placement for Resident #8 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify a resident's representative immediately following a change of condition and failure to provide consistent and thorough dialysis communication forms for residents requiring dialysis.
Complaint Details
The complaint investigation revealed that Resident #3's representative was not notified until the day after the resident was transferred to the hospital following a significant drop in blood pressure. For Resident #2, dialysis communication forms were incomplete or missing for multiple dates in February 2025, and the resident sometimes did not return with the dialysis communication book.
Findings
The facility failed to notify Resident #3's representative immediately after a significant change in condition and hospital transfer. Additionally, the facility failed to consistently complete dialysis communication forms for Resident #2, with missing documentation and incomplete forms noted. Staff interviews and policy reviews confirmed these deficiencies.
Deficiencies (2)
Failure to notify Resident #3's representative immediately following a change of condition and hospital transfer.
Failure to consistently and thoroughly complete dialysis communication forms for Resident #2.
Report Facts
Residents reviewed for notification: 15
Residents reviewed for dialysis: 15
Dialysis sessions scheduled: 11
Dialysis communication forms missing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Assessed Resident #3 during change of condition and provided interview about notification failure |
| RN #2 | Registered Nurse | Failed to notify Resident #3's representative after hospital transfer |
| NHA | Nursing Home Administrator | Provided policy, interviewed regarding notification procedures and follow-up actions |
| LPN #1 | Licensed Practical Nurse | Responsible nurse for Resident #2 on 2/25/25 and interviewed about dialysis communication form completion |
| SSA | Social Services Assistant | Provided dialysis communication logs and information about missing dialysis book |
| NP | Nurse Practitioner | Provided medical oversight and interview regarding Resident #2's condition |
| IDON | Interim Director of Nursing | Provided dialysis communication logs and education plans |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 3, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with safety, sanitation, and comfort standards, specifically focusing on maintaining safe and comfortable temperature levels in resident rooms and common areas, and to evaluate the effectiveness of the pest control program.
Findings
The facility failed to maintain safe and comfortable temperatures in five resident rooms and the activity room, with temperatures below the safe range of 71 to 81 degrees Fahrenheit, causing residents to experience cold conditions. Additionally, the facility failed to maintain an effective pest control program, resulting in ongoing mice infestations in residents' rooms and facility areas.
Deficiencies (2)
Facility failed to ensure temperatures in five of 14 resident rooms and the resident's activity room were within the safe range of 71 to 81 degrees Fahrenheit.
Facility failed to maintain an effective pest control program, resulting in mice infestations in residents' rooms on two of four units.
Report Facts
Resident rooms with temperatures below safe range: 5
Temperature readings: 65
PTAC units working: 2
Mouse sightings: 4
Mouse traps caught: 2
Pest control visits per week: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding ongoing heat problems and thermostat issues. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about residents' complaints of cold and providing extra blankets. |
| Interim Nursing Home Administrator | Interim Nursing Home Administrator | Provided facility policies, conducted audits, coordinated heating repairs, and communicated follow-up actions. |
| Corporate Consultant | Corporate Consultant | Interviewed about heat issues, care plan updates, and temperature monitoring plans. |
| Maintenance Director | Maintenance Director | Conducted temperature readings and discussed heating unit issues. |
| Pest Control Specialist | Pest Control Specialist | Conducted pest control rounds, reported ongoing mice problems, and identified building issues contributing to infestation. |
| Social Service Assistant | Social Service Assistant | Interviewed regarding resident complaints about mice. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 2, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to promptly address resident grievances about Resident #10 wandering into other residents' rooms without permission and concerns about the appointment process of the resident council president. Additionally, the investigation included a complaint of physical abuse between residents.
Complaint Details
The complaint investigation was triggered by grievances from residents about Resident #10 entering their rooms without permission and concerns about the resident council president appointment process. The investigation also included a substantiated physical abuse incident between Resident #4 and Resident #5.
Findings
The facility failed to ensure prompt resolution of grievances related to Resident #10 entering other residents' rooms without permission and did not follow the majority vote process in appointing the resident council president. The facility also failed to protect Resident #5 from physical abuse by Resident #4, which was substantiated.
Deficiencies (2)
Failed to ensure prompt efforts to resolve grievances regarding Resident #10 wandering into residents' rooms and failure to appoint resident council president based on majority vote.
Failed to protect Resident #5 from physical abuse by Resident #4.
Report Facts
Sample residents: 17
Residents with grievances not promptly addressed: 9
Residents interviewed in group: 9
Frequency of Resident #10 entering Resident #7's room: 10
Skin tear size: 1
Skin tear size: 0.75
Skin tear size: 0.2
Bruise size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director (SSD) | Interviewed regarding grievance process and abuse incident | |
| Nursing Home Administrator (NHA) | Interviewed regarding grievance process and resident council president appointment | |
| Regional Nurse Consultant (RNC) | Interviewed regarding grievance process and abuse incident | |
| Certified Nurse Aide (CNA) #1 | Witnessed physical abuse incident between residents |
Inspection Report
Annual Inspection
Census: 144
Deficiencies: 19
Date: Sep 21, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with state and federal regulations for nursing home facilities.
Findings
The facility was found to have multiple deficiencies including failure to promote resident dignity, inadequate access to survey results, unsanitary environment with pest infestation, failure to prevent and investigate abuse, inaccurate resident assessments, inconsistent assistance with activities of daily living, inadequate behavioral health services, medication administration errors, improper medication storage, insufficient dietary staffing and food service issues, failure to follow menus, inadequate infection control practices, incomplete immunization documentation, malfunctioning kitchen equipment, and ineffective pest control.
Deficiencies (19)
Failure to promote dignity and respect for Resident #67 by allowing participation during cleaning and disposal of belongings.
Failure to ensure residents had access to survey results and communicate with advocate agencies.
Failure to provide a clean, comfortable and homelike environment; presence of foul odors, mice, trash, and unsanitary conditions throughout the facility.
Failure to implement policies and procedures to prevent abuse, neglect, and retaliation; failure to post employee rights as mandated reporters.
Failure to timely report suspected abuse of residents #28, #10, and #111 to proper authorities.
Failure to ensure accurate resident assessments including PASRR conditions and immunization documentation for multiple residents.
Failure to consistently provide activities of daily living assistance including grooming, incontinent care, repositioning, and meal assistance for residents #78, #90, and #29.
Failure to provide personalized activity programs and conduct activity assessments for residents #23, #81, #112, and #105.
Failure to ensure proper treatment and assistive devices for vision and hearing for residents #67 and #82.
Failure to provide adequate supervision for resident #8 while smoking and failure to maintain safe water temperatures throughout the facility.
Failure to ensure continuous positive airway pressure (CPAP) equipment for resident #111 was used and maintained according to professional standards and physician orders.
Failure to ensure medication carts were locked when unattended.
Failure to assist resident #8 with obtaining dental services when dentures did not fit causing pain.
Failure to employ sufficient dietary staff and maintain sanitary food service environment; prolonged wait times and leftover food on trays.
Failure to follow menus and ensure food items were served at appropriate temperatures and with proper hand hygiene by food service staff.
Failure to maintain infection control practices including labeling of resident toiletry items and proper hand hygiene by staff and residents.
Failure to maintain an effective pest control program resulting in ongoing mouse infestation throughout the facility.
Failure to conduct a comprehensive facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies.
Failure to implement an effective quality assurance and performance improvement program to identify and address facility-wide deficiencies.
Report Facts
Resident census: 144
Deficiency citations: 19
Deficiency citations: 1
Mice caught: 18
Water temperature: 131.1
Water temperature: 130.1
Insulin dose: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in multiple abuse allegations involving residents #28, #10, and #111 |
| Resident #67's daughter | Reported resident's pain and behavioral concerns | |
| LPN #1 | Licensed Practical Nurse | Observed medication administration and insulin priming |
| LPN #7 | Licensed Practical Nurse | Observed medication pass without hand hygiene |
| CNA #9 | Certified Nurse Aide | Reported resident pain and smoking supervision issues |
| MTD | Maintenance Director | Reported pest control and water temperature issues |
| CDM | Corporate Dietary Manager | Reported kitchen staffing and food service issues |
| NHA | Nursing Home Administrator | Reported leadership turnover and quality assurance plans |
| DON | Director of Nursing | Reported on pain management, infection control, and abuse investigations |
| CNC #1 | Corporate Nurse Consultant | Provided oversight and survey support |
Inspection Report
Census: 66
Deficiencies: 13
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to investigate multiple deficiencies including failure to notify resident representatives of significant changes, failure to maintain a safe and homelike environment, allegations of abuse, inadequate care for activities of daily living, pressure ulcer care, food and nutrition services, pest control, and safety hazards.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of hospital transfers, poor environmental conditions with foul odors and pest infestations, inadequate supervision and investigation of abuse allegations, inconsistent assistance with activities of daily living, failure to prevent and treat pressure ulcers, unsafe food handling and preparation practices, failure to maintain safe water temperatures, inadequate smoking supervision, and failure to maintain essential kitchen equipment and pest control.
Deficiencies (13)
Failure to immediately notify resident representative of resident's hospital transfer and significant change in condition.
Failure to provide a clean, comfortable, and homelike environment including pest control, odor control, cleanliness, and maintenance.
Failure to protect residents from abuse including failure to investigate allegations and prevent further abuse.
Failure to provide consistent assistance with activities of daily living including grooming, incontinent care, repositioning, and eating assistance.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to ensure safe smoking supervision and adherence to smoking policy.
Failure to provide sufficient dietary and food service staff leading to prolonged meal wait times and unsanitary conditions.
Failure to ensure menus were followed and food items were served as planned with appropriate substitutions.
Failure to serve food that was palatable, attractive, and at safe temperatures.
Failure to ensure proper food holding temperatures, hand hygiene, refrigerator thermometers, and cleanable kitchen surfaces.
Failure to dispose of garbage properly and maintain dumpster lids closed to prevent pest harborage.
Failure to maintain essential kitchen equipment in proper working order including walk-in freezer fan causing condensation and icicles.
Failure to maintain an effective pest control program resulting in persistent mouse infestations throughout the facility.
Report Facts
Sample residents reviewed: 66
Pressure ulcer measurement: 3
Pressure ulcer measurement: 6
Water temperature: 131.1
Water temperature: 130.1
Water temperature: 125
Water temperature: 130
Water temperature: 129
Water temperature: 121
Mouse captures: 8
Mouse captures: 23
Pest control service frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in multiple abuse allegations and failure to investigate |
| Resident #28 | Resident alleging abuse by CNA #1 | |
| Resident #111 | Resident alleging verbal abuse by CNA #1 | |
| Director of Nursing | DON | Interviewed regarding abuse investigations and care plans |
| Licensed Practical Nurse #7 | LPN | Interviewed regarding pest control and facility conditions |
| Certified Nurse Aide #15 | CNA | Observed serving food without hand hygiene |
| Corporate Dietary Manager | CDM | Interviewed regarding food service and kitchen conditions |
| Maintenance Director | MTD | Interviewed regarding pest control and kitchen equipment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to ensure residents received adequate nutritional care and interventions to maintain their health and prevent significant weight loss.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to meet the nutritional needs of residents, resulting in significant weight loss and lack of appropriate care planning and interventions.
Findings
The facility failed to implement appropriate nutritional interventions for three residents who experienced significant weight loss. The facility did not obtain timely weights upon admission or readmission, did not follow physician orders for weekly weights, and failed to update care plans accordingly. Nutritional assessments and interventions were inadequate, and the facility did not properly monitor or address residents' declining nutritional status.
Deficiencies (1)
Failure to provide adequate nutritional care and interventions to maintain residents' health and prevent significant weight loss.
Report Facts
Weight loss percentage: 11
Weight loss percentage: 10.4
Weight loss percentage: 7.7
Weight loss percentage: 4.3
Weight loss percentage: 8.5
Weight loss percentage: 11.5
Weight loss percentage: 8.2
Weight loss percentage: 6
Weight loss percentage: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 21, 2023
Visit Reason
The inspection was conducted due to investigations of resident-to-resident physical abuse incidents involving two separate altercations between residents in the facility.
Complaint Details
The complaint investigations substantiated physical abuse between Resident #1 and Resident #2 on 2/2/23, and between Resident #5 and Resident #6 on 1/6/23. Both incidents were witnessed and documented by staff, with appropriate notifications made to physicians and parties involved.
Findings
The facility failed to prevent two substantiated resident-to-resident physical abuse incidents: one where Resident #1 flipped Resident #2's wheelchair causing injury, and another where Resident #5 struck Resident #6 causing a bruise and scratch. The facility conducted investigations, separated the residents involved, increased supervision, and provided staff education on abuse prevention.
Deficiencies (1)
Failed to protect residents from resident-to-resident physical abuse, specifically incidents involving Resident #1 and Resident #2, and Resident #5 and Resident #6.
Report Facts
Residents affected: 2
Incident dates: 1/6/23 and 2/2/23
15 minute checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding incident and medical treatment of Resident #2 |
| CNA #1 | Certified Nursing Aide | Witnessed the incident between Resident #1 and Resident #2 and provided statements |
| NHA | Nursing Home Administrator | Provided facility abuse investigation reports and interviewed regarding abuse incidents and corrective actions |
| DON | Director of Nursing | Interviewed regarding resident behaviors and facility response to incidents |
Inspection Report
Routine
Deficiencies: 9
Date: Sep 25, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities, medication management, respiratory care, smoking safety, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity, incomplete care plans for pain, falls, and pressure injuries, inadequate activity programs, failure to follow physician orders for respiratory care, unsafe smoking practices, delayed pharmacy recommendation follow-up, unnecessary psychotropic medication use, and improper medication storage and labeling.
Deficiencies (9)
Failed to ensure Resident #109 was treated with respect and dignity, causing embarrassment during a smoking incident.
Failed to develop comprehensive person-centered care plans for Residents #76, #335, and #336 including pain, falls, antipsychotic use, and stage III pressure injury.
Failed to provide an ongoing program of activities to meet the interests and wellbeing of Resident #67.
Failed to provide treatment and care according to orders and resident preferences for Resident #67's lower legs, including use of compression stockings and shin guards.
Failed to ensure safe smoking practices for Residents #109, #13, and #9 and failed to assess Resident #109 for safe smoking at admission.
Failed to obtain oxygen orders for Resident #108 and failed to follow physician oxygen orders for Resident #121.
Failed to ensure pharmacy recommendations were reviewed and acted upon timely for Residents #31 and #124.
Failed to track target behaviors, assess for other causes of behavior, use non-pharmacological approaches, and document risks and benefits of antipsychotic medication for Resident #76; and failed to discontinue PRN antipsychotic medication after 14 days for Resident #31.
Failed to remove expired medications, properly label prescription medications with resident names, date insulin when opened, and store medications in original packaging on medication carts.
Report Facts
Residents affected: 53
Residents affected: 28
Residents affected: 3
Medication doses missing: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Compliance Specialist (CCS) | Involved in smoking incident with Resident #109 | |
| Nursing Home Administrator (NHA) | Interviewed regarding smoking policies, resident incidents, and facility follow-up | |
| Director of Nursing (DON) | Interviewed regarding care plans, medication management, and facility policies | |
| Corporate Nurse Consultant (CNC) | Interviewed regarding pharmacy recommendations and medication management | |
| Assistant Director of Nursing (ADON) | Interviewed regarding medication orders and resident care | |
| Registered Nurse #2 | Interviewed regarding oxygen orders and medication administration | |
| Certified Nurse Aide (CNA) #2 | Interviewed regarding resident activities and care | |
| Unit Manager #2 | Interviewed regarding resident activities and care | |
| Registered Nurse #3 | Interviewed regarding medication administration and missing doses | |
| Agency Nurse #1 | Observed medication cart and commented on medication storage | |
| Unit Manager #1 | Interviewed regarding medication cart checks | |
| Registered Nurse #1 | Observed medication cart and insulin pens |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 20, 2018
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, assistance with activities of daily living, accident prevention, and resident care in a nursing facility.
Findings
The facility failed to administer medications timely and notify physicians of medication errors for several residents, failed to provide timely toileting and shaving assistance to dependent residents, and failed to ensure safe transfer procedures and fall prevention measures for residents requiring assistance.
Deficiencies (3)
Failed to administer medications timely to Residents #59 and #123 and notify physicians timely of medication errors; failed to notify physician of held blood pressure medication for Resident #114.
Failed to provide timely toileting assistance for Residents #41 and #26 and shaving assistance for Resident #82.
Failed to ensure safe transfers and follow fall interventions for Residents #76 and #26.
Report Facts
Residents reviewed: 39
Residents reviewed for ADLs: 5
Residents reviewed for accidents: 5
Medication administration time: 7
Medication administration time: 5
Medication administration time: 7
Observation period: 7
Toileting assistance delay: 6.5
BIMS scores: 15
BIMS score: 13
BIMS score: 3
Fall date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in medication administration and error findings for Residents #59 and #123 |
| LPN #2 | Licensed Practical Nurse | Named in medication holding and notification finding for Resident #114 |
| CNA #5 | Certified Nurse Aide | Involved in toileting assistance observation for Resident #41 |
| CNA #6 | Certified Nurse Aide | Involved in toileting assistance observation for Resident #41 |
| CNA #2 | Certified Nurse Aide | Named in toileting assistance failure for Resident #26 |
| CNA #7 | Certified Nurse Aide | Observed transferring Resident #76 without proper use of gait belt |
| CNA #8 | Certified Nurse Aide | Observed transferring Resident #76 without proper use of gait belt |
| CNA #4 | Certified Nurse Aide | Named in fall incident and transfer failure for Resident #26 |
| DON | Director of Nursing | Provided policies, interviews, and education related to deficiencies |
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