Inspection Reports for
Casey’s Pond Senior Living
2855 OWL HOOT TRAIL, STEAMBOAT SPRINGS, CO, 80487-
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse and inappropriate touching between residents, as well as concerns about medication administration, oxygen therapy, and care practices.
Complaint Details
The complaint investigation was substantiated. The facility failed to protect Resident #22 from sexual abuse by Resident #26. The investigation included interviews, record reviews, and observations confirming inappropriate sexual behavior and inadequate supervision. Additional complaints about medication administration, oxygen therapy, and cervical collar management were also substantiated.
Findings
The facility failed to protect a resident from sexual abuse by another resident, failed to follow professional standards in medication administration and oxygen therapy, and did not consistently assist a resident with removing a cervical collar during meals. Controlled medications were also not stored in a locked, permanently affixed compartment in the medication refrigerator.
Deficiencies (4)
F 0600: The facility failed to protect Resident #22 from sexual abuse by Resident #26 despite awareness of Resident #26's hypersexual behaviors and history of inappropriate touching.
F 0658: The facility failed to follow accepted standards for medication administration by pre-pouring medications and not destroying them when the resident was unavailable.
F 0684: The facility failed to ensure Resident #7's portable oxygen concentrator was turned on during an outside appointment and failed to assist Resident #49 with removing her cervical collar during meals.
F 0761: The facility failed to ensure controlled medications were stored in a locked storage container permanently affixed to the medication refrigerator.
Report Facts
Residents affected: 1
Residents affected: 4
Oxygen saturation level: 87
Oxygen saturation level: 92
Medication administration delay: 68
Medication administration delay: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed pre-pouring medications and interviewed regarding medication administration practices |
| DON | Director of Nursing | Provided facility policies, interviewed regarding medication and controlled substance storage, and provided staff education |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #49's cervical collar management and Resident #7's oxygen therapy |
| CNA #3 | Certified Nurse Aide | Interviewed regarding assistance with Resident #49's cervical collar |
| CNA #4 | Certified Nurse Aide | Interviewed regarding assistance with Resident #49's cervical collar |
| SSD | Social Service Director | Interviewed regarding Resident #26's inappropriate sexual behaviors and facility investigation |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding witnessing Resident #26's inappropriate sexual behavior |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 31, 2019
Visit Reason
The inspection was conducted as part of the annual survey of Casey's Pond Senior Living to assess compliance with regulatory standards related to resident care, medication administration, activities of daily living assistance, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during dining assistance, improper medication administration and self-administration assessments, inadequate assistance with activities of daily living, unsafe food handling and storage practices, and lapses in infection control practices related to blood glucose monitoring.
Deficiencies (5)
F 0550: The facility failed to assist Resident #27 with dining at the resident's eye level and failed to interact appropriately during meal assistance, compromising the resident's dignity.
F 0658: The facility failed to administer medications according to professional standards for Residents #39 and #30, including leaving medications at the bedside without timely physician orders and assessments for self-administration.
F 0677: The facility failed to provide timely assistance with eye and facial cleanliness for Resident #36, resulting in crusted debris and poor grooming.
F 0812: The facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions, including inadequate hand hygiene, unsafe cold food storage, and unclean food contact and non-food contact surfaces.
F 0880: The facility failed to implement infection control standards during blood glucose monitoring for Residents #15, #5, and #13, including failure to disinfect devices, improper disposal of contaminated materials, and lack of appropriate PPE use.
Report Facts
Residents reviewed: 39
Residents reviewed for medication administration: 11
Residents reviewed for blood glucose monitoring: 34
Medication pills in cup: 7
BIMS score: 12
BIMS score: 15
BIMS score: 3
Temperature reading: 71
Days without temperature logs: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and blood glucose monitoring findings |
| RN #4 | Registered Nurse | Named in blood glucose monitoring findings |
| CNA #3 | Certified Nurse Aide | Named in dignity and respect during dining assistance finding |
| CNA #6 | Certified Nurse Aide | Interviewed regarding dining assistance standards |
| CNA #8 | Certified Nurse Aide | Interviewed regarding dining assistance standards |
| CNA #7 | Certified Nurse Aide | Interviewed regarding dining assistance standards |
| CNA #2 | Certified Nurse Aide | Interviewed regarding dining assistance standards |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and blood glucose monitoring |
| RN #1 | Registered Nurse | Completed medication self-administration assessment for Resident #39 |
| CNA #12 | Certified Nurse Aide | Interviewed regarding Resident #39 medication and Resident #36 ADL care |
| CNA #10 | Certified Nurse Aide | Fed Resident #36 lunch without offering to wash hands or face |
| CNA #11 | Certified Nurse Aide | Interviewed regarding Resident #36 grooming |
| DSM | Dining Services Manager | Interviewed regarding food service deficiencies |
| DON | Director of Nursing | Interviewed regarding multiple findings including dining assistance, medication administration, ADL care, and infection control |
| CNC | Corporate Nurse Consultant | Interviewed regarding multiple findings including dining assistance, medication administration, ADL care, and infection control |
Inspection Report
Routine
Deficiencies: 11
Date: Nov 15, 2018
Visit Reason
Routine inspection of Casey's Pond Senior Living to assess compliance with regulatory requirements including resident care, medication administration, staffing, dining services, infection control, and safety.
Findings
The facility had multiple deficiencies including failure to provide dignified care to residents, inadequate notification of Medicare coverage changes, inaccurate resident assessments, failure to administer oxygen therapy as ordered, insufficient nursing and dietary staffing, inadequate dementia care, incomplete psychotropic medication documentation, prolonged meal wait times, unsafe food handling and storage, improper infection control practices, and malfunctioning call light systems.
Deficiencies (11)
F0550: The facility failed to provide dignified care to Resident #17, including lack of verbal interaction, ignoring requests for assistance, and rough handling during transfers.
F0582: The facility failed to provide timely Medicare non-coverage notices to Residents #500 and #46, omitting required information and options for appeal.
F0641: The facility failed to ensure accuracy of MDS assessments for Residents #43 and #51 regarding use of personal alarms, which were documented as not used but were in use.
F0695: The facility failed to administer oxygen therapy as ordered for Residents #2, #12, #13, and #35, with incorrect flow rates and residents not wearing oxygen devices properly.
F0725: The facility failed to provide sufficient nursing staff, resulting in delayed call light response, assistance with activities of daily living, and prolonged meal wait times for 17 residents.
F0744: The facility failed to provide person-centered dementia care for Resident #43, lacking comprehensive assessment, detailed care plans, staff training, and non-pharmacological interventions.
F0758: The facility failed to ensure Resident #9 was free from unnecessary psychotropic medications and failed to document consistent monitoring of medication effectiveness and side effects.
F0802: The facility failed to employ sufficient dietary support staff, contributing to prolonged meal wait times and decreased resident satisfaction with dining.
F0812: The facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions, including inadequate hand washing, insufficient sanitation of work surfaces, and failure to monitor refrigerator temperatures.
F0880: The facility failed to properly disinfect and store blood glucose monitoring devices after use for Resident #8, risking cross contamination.
F0919: The facility failed to ensure the resident call light system was fully functional and call light requests were not dismissed prior to residents receiving assistance.
Report Facts
Resident census: 52
Residents needing assistance with dressing: 42
Residents needing assistance with bathing: 23
Residents needing assistance with transfers: 35
Residents incontinent of bladder: 31
Bedfast residents: 6
Residents with dementia or Alzheimer's disease: 28
Residents receiving respiratory treatment: 25
Call light alerts never responded to: 50
Refrigerator temperature: 50
Refrigerator temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Named in dignity care failure and dementia care interviews |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including dignity care, oxygen therapy, staffing, dementia care, psychotropic medication, infection control, and call light system |
| NHA | Nursing Home Administrator | Interviewed regarding staffing, psychotropic medication documentation, and call light system |
| RN #1 | Registered Nurse | Interviewed regarding call light system and staffing |
| RN #3 | Registered Nurse | Interviewed regarding call light system and staffing |
| RN #5 | Registered Nurse | Interviewed regarding staffing and call light system |
| IT | Information Technologist | Interviewed regarding call light system functionality and maintenance |
| Interim FSD | Interim Food Service Director | Interviewed regarding dietary staffing, food safety, and sanitation |
| RD | Registered Dietitian | Interviewed regarding dietary staffing, food safety, and sanitation |
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding blood glucose monitoring infection control |
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