Inspection Reports for
Cedars Healthcare Center Rehab, Skilled Nursing & Short Term Care
1599 Ingalls St, Lakewood, CO 80214, CO, 80214
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
14 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
169% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
26% occupied
Based on a March 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Enforcement
Deficiencies: 2
Date: Jul 16, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate treatment and care according to orders, resident preferences, and goals, specifically related to seizure management and medication administration.
Findings
The facility failed to ensure timely assessment and intervention during a resident's prolonged seizure episode, failed to provide seizure-specific staff training, and did not obtain or administer breakthrough seizure medication in a timely manner. Additionally, the facility failed to maintain accurate medication administration records for multiple residents.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals, resulting in immediate jeopardy to resident health or safety related to seizure management.
Failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, including accurate documentation of medication administration.
Report Facts
Residents reviewed for quality of care: 7
Residents affected by immediate jeopardy deficiency: 1
Days delay in obtaining midazolam medication: 6
Pages in report: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in seizure management failure and medication administration delay. |
| LPN #4 | Licensed Practical Nurse | Named in seizure management failure and communication with NP. |
| RN #3 | Registered Nurse | Named in communication with NP and care conference. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding seizure incident, staff training, and medication administration. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided plan to remove immediate jeopardy. |
| Nurse Practitioner | Nurse Practitioner (NP) | Involved in communication and physician orders during seizure event. |
| Medical Director | Medical Director (MD) | Interviewed regarding notification and assessment issues. |
| Staff Development Coordinator | Staff Development Coordinator (SDC) | Responsible for staff education on seizure management. |
| LPN #1 | Licensed Practical Nurse | Interviewed about seizure protocol knowledge. |
| RN #1 | Registered Nurse | Interviewed about seizure management practices. |
| LPN #3 | Licensed Practical Nurse | Interviewed about seizure monitoring and response. |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed about seizure monitoring training. |
| Certified Nurse Aide #2 | Certified Nurse Aide (CNA) | Interviewed about seizure monitoring responsibilities. |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication administration documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 16, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate treatment and care for residents, specifically related to seizure management and medication administration.
Complaint Details
The complaint investigation revealed that Resident #7 experienced prolonged seizure activity without timely assessment or intervention, resulting in hospitalization and ICU admission. The facility also failed to provide seizure-specific staff training and timely medication administration. For Residents #1 and #2, the facility failed to accurately document medication administration, including missed doses and lack of progress notes explaining omissions.
Findings
The facility failed to provide timely assessment and intervention during seizure activity for Resident #7, resulting in immediate jeopardy to resident health. Additionally, the facility failed to maintain accurate medication administration records for Residents #1 and #2, leading to potential harm.
Deficiencies (2)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in immediate jeopardy due to inadequate seizure monitoring and delayed emergency response for Resident #7.
F 0842: The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards for Residents #1 and #2.
Report Facts
Residents reviewed for quality of care: 7
Residents reviewed for medication documentation: 6
Days medication not documented: 24
Days medication not documented: 20
Seizure duration: 30
Days delay in medication delivery: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in failure to assess and document seizure activity for Resident #7. |
| LPN #4 | Licensed Practical Nurse | Named in failure to assess and document seizure activity for Resident #7. |
| RN #3 | Registered Nurse | Named in failure to assess and document seizure activity and communication with NP for Resident #7. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding seizure incident and medication administration failures. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided plan of correction to remove immediate jeopardy. |
| Nurse Practitioner | Nurse Practitioner (NP) | Named in delayed response and failure to request resident assessment during seizure activity. |
Inspection Report
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care related to treatment and care for optimal skin condition of a resident with hand contractures.
Findings
The facility failed to provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between the resident's fingers and thumb, resulting in pressure wounds and skin issues. The facility lacked policies on contracture and skin integrity management and faced challenges with resident and family cooperation regarding splint use and wound care.
Deficiencies (1)
Failure to provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between fingers and thumb.
Report Facts
Residents affected: 3
Residents affected: 1
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding Resident #1's care and wound management | |
| Director of Nursing (DON) | Interviewed regarding facility policies and family cooperation on Resident #1's care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate treatment and care for optimal skin condition of a resident's contracted hand.
Complaint Details
The complaint investigation found that Resident #1 did not receive consistent preventative care for hand contractures, leading to skin breakdown and wounds. The resident and family reported frequent foul odor, redness, and moisture buildup due to lack of proper hygiene and inconsistent use of splints and protective materials.
Findings
The facility failed to provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between the fingers and thumb, resulting in open wounds and skin issues related to moisture and pressure. Staff and family interviews confirmed inconsistent care and resistance to recommended splint use.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in inadequate skin care for Resident #1's contracted hands and skin breakdown between fingers and thumb.
Report Facts
Residents in sample: 5
Residents affected: 1
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding Resident #1's care and noted lack of orders for absorbent materials and inconsistent splint use | |
| Director of Nursing (DON) | Interviewed about facility efforts to manage Resident #1's contractures and wound care, and family involvement |
Inspection Report
Routine
Census: 34
Deficiencies: 7
Date: Mar 19, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without proper evaluation or consent, failure to conduct timely PASRR screening, inadequate assistance with activities of daily living, improper catheter care, failure to provide trauma-informed care, medication labeling and storage issues, and deficiencies in infection prevention and control practices.
Deficiencies (7)
Failed to ensure residents were free from physical restraints without proper evaluation, consent, and physician orders for two residents.
Failed to conduct a preadmission screening resident review (PASRR) for a resident remaining beyond provisional admission approval.
Failed to ensure dependent resident received scheduled showers as required.
Failed to provide appropriate care and services for a resident with an indwelling catheter, including lack of physician orders, clinical indication, care plan, and proper catheter drainage bag handling.
Failed to provide trauma-informed and culturally competent care for a resident with PTSD, including lack of assessment, care plan, and identification of triggers.
Failed to ensure medications and biologicals were properly labeled with open dates and expired or discontinued medications were removed from medication carts and storage rooms.
Failed to maintain an effective infection prevention and control program, including improper cleaning techniques, lack of training and supervision of housekeeping staff, failure to disinfect high-touch surfaces, and non-adherence to disinfectant dwell times.
Report Facts
Residents reviewed: 34
Resident census: 34
Showers received: 6
Showers refused: 4
Insulin open date: 28
Expired IV antibiotics: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding restraint use for Resident #180 |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding restraint evaluation for Resident #180 |
| Director of Nursing | Director of Nursing | Interviewed regarding restraint policies, PASRR screening, catheter care, trauma-informed care, medication management, and infection control |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding shower schedules and catheter care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding shower schedules, catheter care, and trauma-informed care |
| Social Service Assistant | Social Service Assistant | Interviewed regarding PASRR screening and trauma-informed care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication labeling and storage |
| Housekeeper #1 | Housekeeping Staff | Interviewed regarding cleaning procedures and training |
| Housekeeper #2 | Housekeeping Staff | Interviewed regarding cleaning procedures and training |
| Housekeeping Director | Housekeeping Director | Interviewed regarding housekeeping deficiencies and training needs |
| Infection Preventionist | Infection Preventionist | Interviewed regarding catheter care and infection prevention |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 19, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without proper evaluation and consent, failure to conduct timely PASRR screening, inadequate assistance with activities of daily living, improper catheter care, failure to provide trauma-informed care for a resident with PTSD, improper medication labeling and storage, and deficiencies in housekeeping and infection control practices.
Deficiencies (7)
F 0604: The facility failed to ensure residents were free from physical restraints without proper evaluation, consent, and physician orders for Residents #180 and #40.
F 0645: The facility failed to conduct a preadmission screening resident review (PASRR) for Resident #56 who remained in the facility beyond the 30-day provisional admission approval.
F 0677: The facility failed to ensure Resident #64, dependent on staff for bathing, received scheduled showers as documented by missed showers and refusals.
F 0690: The facility failed to ensure Resident #74 with an indwelling catheter had physician orders, clinical indication, a care plan, and proper catheter drainage bag placement.
F 0699: The facility failed to provide trauma-informed care for Resident #56 by not identifying PTSD triggers or providing a care plan with individualized interventions.
F 0761: The facility failed to ensure insulin pens and vials were labeled with open dates and expired or discontinued medications were removed from medication carts and storage rooms.
F 0880: The facility failed to maintain an infection control program by not ensuring housekeeping staff followed proper cleaning techniques, were trained appropriately, and adhered to disinfectant dwell times.
Report Facts
Sample residents reviewed: 34
Residents affected by restraint deficiency: 2
Residents affected by PASRR deficiency: 1
Residents affected by ADL deficiency: 1
Residents affected by catheter care deficiency: 1
Residents affected by trauma-informed care deficiency: 1
Insulin pens not labeled: 2
Expired IV antibiotic bags: 3
Shower opportunities for Resident #64: 24
Showers received by Resident #64: 6
Shower refusals by Resident #64: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding restraint use for Resident #180 |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about restraint evaluation for Resident #180 |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding restraint, PASRR, catheter care, medication storage, and infection control |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about shower schedules and catheter care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about shower schedules, catheter care, and trauma-informed care |
| Social Service Assistant | Social Service Assistant | Interviewed about PASRR screening and trauma-informed care for Resident #56 |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication labeling and expired medications |
| Housekeeper #1 | Housekeeper | Interviewed about cleaning procedures and training |
| Housekeeper #2 | Housekeeper | Interviewed about cleaning procedures and training |
| Housekeeping Director | Housekeeping Director | Interviewed about housekeeping deficiencies and training needs |
| Infection Preventionist | Infection Preventionist | Interviewed about catheter care and infection prevention |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 17, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide necessary care and assistance with activities of daily living and mobility for Resident #4, and failure to provide appropriate treatment and care for Resident #1's non-pressure related skin condition resulting in osteomyelitis, hospitalization, and amputation.
Complaint Details
The complaint investigation revealed substantiated findings that the facility failed to assist Resident #4 with mobility and going outside as requested, and failed to identify and respond to Resident #1's worsening non-pressure related skin condition, resulting in serious harm including hospitalization and amputation.
Findings
The facility failed to ensure Resident #4 received assistance with mobility and going outside as per care plan, and failed to identify and respond appropriately to Resident #1's non-pressure related skin condition, leading to serious harm including amputation. Immediate jeopardy was identified but removed after the facility implemented corrective actions including staff education and systemic changes.
Deficiencies (2)
Failure to provide necessary care and assistance with mobility consistent with Resident #4's needs and choices.
Failure to provide appropriate treatment and care according to orders, resulting in osteomyelitis and amputation of Resident #1's left great toe.
Report Facts
Residents affected: 3
Hospitalization duration: 8
Braden scale score: 14
Education completion date: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Completed skin assessment on Resident #1 on 10/3/23 and documented no wounds; interviewed regarding wound care failures. |
| LPN #3 | Licensed Practical Nurse | Interviewed about wound assessments and reporting; last saw Resident #1's scab four days before 10/6/23. |
| LPN #1 | Licensed Practical Nurse, Wound Care Nurse | Conducted wound care rounds and was not notified about Resident #1's scab. |
| Certified Nurse Aide #1 | CNA | Interviewed about assisting residents outside and observations related to Resident #4 and Resident #1. |
| Director of Nursing | DON | Interviewed about facility policies, wound care failures, and immediate jeopardy removal plan. |
| Activities Director | AD | Interviewed about activities assistance and Resident #4's participation. |
| Medical Director | MD | Interviewed about wound care and Resident #1's risk factors and wound development. |
Inspection Report
Routine
Census: 81
Deficiencies: 2
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with policies and procedures related to pneumococcal immunizations for residents.
Findings
The facility failed to implement proper policies and procedures for pneumococcal vaccinations, including failure to administer the vaccine after consent for some residents and failure to offer the vaccine yearly after refusal for others. Several residents had consents signed but did not receive the vaccine.
Deficiencies (2)
Failed to administer pneumococcal vaccine after consent for Resident #2 and #5
Failed to offer pneumococcal vaccination yearly after refusal for Resident #1, #3, and #8
Report Facts
Resident census: 81
Residents coded as receiving pneumococcal vaccination: 31
Residents reviewed for immunizations: 8
Residents with failed pneumococcal immunization procedures: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding immunization policies and procedures | |
| Infection Preventionist (IP) | Interviewed regarding immunization records and facility procedures |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess compliance with pneumococcal vaccination policies and procedures at Cedars Healthcare Center during the annual survey.
Findings
The facility failed to implement proper policies and procedures related to pneumococcal immunizations for five of eight residents reviewed. Specifically, two residents who consented to vaccination did not receive it, and three residents who refused vaccination were not offered it yearly thereafter.
Deficiencies (1)
F 0883: The facility failed to administer the pneumococcal vaccine after consent was signed for Residents #2 and #5. The facility also failed to offer the pneumococcal vaccination yearly after refusal to Residents #1, #3, and #8.
Report Facts
Resident census: 81
Residents receiving pneumococcal vaccination: 31
Residents reviewed for immunizations: 8
Residents with immunization deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding pneumococcal vaccination policies and procedures | |
| Infection Preventionist (IP) | Interviewed regarding review of medical records and vaccination compliance |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to honor residents' rights to self-determination and choice, failure to maintain a safe and comfortable environment, and failure to provide appropriate assistance with activities of daily living including incontinence care.
Complaint Details
The complaint investigation focused on Resident #1's right to shower according to preference, temperature issues causing discomfort and rashes, and pervasive urine odors due to inadequate incontinence care for Residents #6, #5, and #2. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure consistent showers according to resident preferences, maintain safe temperature ranges in resident areas, and provide adequate incontinence care resulting in odors and discomfort. Several residents were affected by these deficiencies, with documentation and care practices not meeting facility policies.
Deficiencies (3)
Failed to provide consistent showers for Resident #1 according to his preferences and routine shower schedule.
Failed to ensure temperatures in hallways, dining room, and resident rooms were within the safe range of 71°F to 81°F.
Failed to provide and document regular incontinence care to prevent odors throughout the facility affecting multiple residents.
Report Facts
Showers received vs scheduled: 5
Showers received vs scheduled: 4
Showers received vs scheduled: 2
Temperature: 85
Temperature: 78
Toileting assistance frequency: 1.3
Toileting assistance frequency: 1.2
Toileting assistance frequency: 0.63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide #2 | CNA | Interviewed regarding shower scheduling and refusals for Resident #1. |
| Certified Nursing Aide #3 | CNA | Interviewed about shower refusals and scheduling for residents. |
| Director of Nursing | DON | Interviewed about shower frequency recommendations, documentation, and incontinence care. |
| Maintenance Director | MTD | Interviewed about temperature monitoring and facility heating system. |
| Nursing Home Administrator | NHA | Interviewed about facility policies, grievance handling, and temperature concerns. |
| Maintenance Worker #1 | MW | Interviewed about temperature complaints and mitigation efforts. |
| Certified Nurse Aide #1 | CNA | Interviewed about incontinence care for Resident #6. |
| Housekeeper #1 | HSKP | Interviewed about odor control efforts in the facility. |
Inspection Report
Routine
Deficiencies: 10
Date: Dec 1, 2022
Visit Reason
Routine state inspection survey of Cedars Healthcare Center to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to ensure resident participation in care planning, inadequate environmental cleanliness, failure to prevent resident-to-resident abuse, insufficient assistance with activities of daily living, inadequate activities programming, medication administration errors, unsafe medication self-administration practices, ineffective dementia care interventions, and lapses in infection control practices.
Deficiencies (10)
F 0553: Facility failed to ensure Resident #45 participated in care plan meetings; no documented care conferences after admission.
F 0584: Facility failed to maintain a clean, comfortable environment during renovation; resident rooms had debris, trash, and belongings improperly stored.
F 0600: Facility failed to prevent resident-to-resident physical abuse between Residents #18 and #32 and between Residents #40 and #74; investigations and follow-up assessments were inadequate.
F 0677: Facility failed to provide timely showers and repositioning for Residents #42, #14, and #65, increasing risk of skin breakdown.
F 0679: Facility failed to provide adequate one-to-one activities for Residents #48, #45, and #5; activities director was uncertified and lacked a system to identify residents needing services.
F 0680: Facility failed to employ a qualified activities director; current director lacked certification and consultant support.
F 0689: Facility failed to ensure Resident #37 did not keep unauthorized medications at bedside; self-administration assessment and physician orders were lacking.
F 0744: Facility failed to provide effective person-centered interventions for Resident #28 with dementia who wandered into other residents' rooms.
F 0760: Resident #177 was sent to hospital for blood infusion without receiving morning medications as ordered.
F 0880: Facility failed to maintain infection control; cleaning procedures did not follow manufacturer dwell times, gloves and mop heads were reused improperly, and oxygen tubing was stored on the floor and not replaced when contaminated.
Report Facts
Residents in sample: 42
One-to-one activity visits for Resident #48: 2
One-to-one activity visits for Resident #45: 4
One-to-one activity visits for Resident #5: 5
Showers received by Resident #65: 3
Medication administration delay: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication left at bedside for Resident #37 |
| Housekeeper #1 | Housekeeper | Observed cleaning resident rooms with improper disinfection practices |
| Activity Director | Activity Director | Uncertified, interviewed about activities program deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including abuse investigations, activities, and infection control |
| Nursing Home Administrator | NHA | Interviewed regarding facility operations and deficiencies |
Inspection Report
Routine
Census: 66
Deficiencies: 18
Date: Aug 18, 2021
Visit Reason
Routine inspection of Cedars Healthcare Center to assess compliance with healthcare regulations, resident care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, care planning participation, environmental safety, grievance processes, abuse reporting and investigation, activities of daily living assistance, medication administration, respiratory care, staffing adequacy, social services, medication labeling, and infection control practices.
Deficiencies (18)
F 0550: The facility failed to ensure resident dignity and respect by not addressing racial slurs and derogatory name calling among residents, and not responding to grievances related to these incidents.
F 0553: The facility failed to ensure residents #50, #2, and #36 were invited and included in care conferences to participate in their person-centered plan of care.
F 0574: The facility failed to ensure residents received notices in a format and location accessible to them, with postings behind locked doors and missing contact information.
F 0584: The facility failed to provide a safe, sanitary, and comfortable environment for Resident #44 by not repairing a bathroom with mold, black substance, and damaged baseboards, resulting in the resident being unable to use the bathroom.
F 0585: The facility failed to maintain an effective grievance process, resulting in unaddressed resident concerns and lack of documentation of grievance follow-up.
F 0609: The facility failed to timely report an alleged abuse incident involving Resident #2 to the State Agency and failed to conduct a thorough investigation.
F 0610: The facility failed to timely and thoroughly investigate an allegation of physical abuse reported by Resident #2, including incomplete interviews and delayed reporting.
F 0676: The facility failed to provide bathing according to resident preferences for Residents #65, #50, #37, #20, and #34, resulting in missed showers and inadequate assistance.
F 0679: The facility failed to provide personalized activity programs for Residents #12 and #22, resulting in lack of stimulation and engagement as documented in care plans.
F 0684: The facility failed to provide treatment and care according to physician orders for Residents #18, #50, #35, #37, and #56, including medication administration, notification of condition changes, and provision of needed equipment.
F 0688: The facility failed to ensure Residents #24, #22, and #65 received appropriate restorative services and assistance to maintain or improve range of motion and prevent contractures.
F 0689: The facility failed to ensure fall prevention measures for Resident #12, including placement of a fall mat by the bedside, resulting in increased risk of injury.
F 0693: The facility failed to provide enteral feedings according to physician orders for Resident #22, including missed feedings and lack of documentation and notification.
F 0695: The facility failed to provide appropriate respiratory care for Residents #56, #50, #35, #31, and #61, including failure to replace and label oxygen tubing, follow oxygen administration orders, and replace damaged equipment.
F 0725: The facility failed to provide sufficient nursing staff with appropriate competencies and skills to meet resident care needs, resulting in delayed call light response and missed assistance with activities of daily living.
F 0745: The facility failed to provide medically-related social services to ensure Residents #2, #16, #44, #35, #18, and #31 received needed ancillary services including eye glasses and dental care.
F 0761: The facility failed to ensure all drugs and biologicals were labeled with open dates and expired medications removed from medication carts on Broadway, Main, and University units.
F 0880: The facility failed to implement an effective infection prevention and control program, including improper use of PPE by staff, failure to assist residents with hand hygiene before meals, improper COVID-19 testing procedures, and inadequate housekeeping training and practices.
Report Facts
Resident census: 66
Residents needing assistance with bathing: 54
Residents dependent on bathing: 12
Residents needing assistance with toilet use: 58
Residents dependent on toilet use: 3
Residents needing assistance with dressing: 60
Residents dependent on dressing: 4
Residents needing assistance with transfers: 35
Residents dependent on transfers: 13
Residents needing assistance with eating: 29
Residents dependent on eating: 4
Residents independent in bathing: 1
Residents independent in toilet use: 5
Residents independent in dressing: 2
Residents independent in transfers: 18
Residents independent in eating: 33
Medication administration frequency: 6
Resident #24 ROM exercises documented: 1
Resident #22 ROM exercises July 2021: 28
Resident #22 hand hygiene July 2021: 14
Resident #22 ROM exercises August 2021: 4
Resident #22 hand hygiene August 2021: 4
Resident #35 weight gain: 128
Resident #35 sling order delay: 74
Resident #22 tube feeding hours: 18
Resident #22 tube feeding volume: 990
Resident #22 tube feeding rate: 55
Resident #56 glucometer reading discrepancy: 89
Resident #35 oxygen tubing age: 4.5
Resident #31 oxygen flow rate incorrect: 1
Resident #12 fall mat missing: 3
Medication carts with unlabeled meds: 3
Medication carts with expired meds: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Observed wearing cloth mask below nose in isolation room and hallway, stated unable to wear surgical or N95 mask |
| DON | Director of Nursing | Interviewed multiple times regarding staffing, infection control, medication cart management, abuse investigations, and resident care |
| RCNA #2 | Restorative Certified Nurse Assistant | Interviewed about restorative therapy program and resident #22 care |
| SW | Social Worker | Interviewed about ancillary services and grievance process |
| HSK #1 | Housekeeper | Observed cleaning practices and interviewed about chemical training |
| HSK #2 | Housekeeper | Observed cleaning practices and interviewed about chemical training |
| CNA #3 | Certified Nurse Aide | Interviewed about resident #18 seizure reporting and shower assistance |
| LPN #1 | Licensed Practical Nurse | Interviewed about medication administration and labeling |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 14
Date: Aug 11, 2021
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident rights violations, dignity, respect, care planning participation, staff responsiveness, and infection control practices.
Complaint Details
The complaint investigation was triggered by multiple resident grievances and concerns including racial discrimination, inadequate care, failure to respond to grievances, and infection control issues. The facility was found to have substantiated deficiencies in these areas.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident verbal abuse and discrimination, failure to ensure resident participation in care planning, inadequate response to grievances, failure to maintain a safe and sanitary environment, insufficient assistance with activities of daily living, failure to provide timely ancillary services, medication administration errors, inadequate respiratory care, insufficient staffing, improper infection control practices, and failure to properly label and store medications.
Deficiencies (14)
Failure to prevent resident-to-resident verbal abuse and discrimination including racial slurs.
Failure to ensure residents participated in care planning and care conferences.
Failure to provide a safe, sanitary, and comfortable environment for residents.
Failure to provide prompt efforts to resolve resident grievances.
Failure to timely report and investigate alleged abuse.
Failure to provide assistance with activities of daily living including bathing according to resident preferences.
Failure to provide personalized activity programs and engagement for residents.
Failure to follow physician orders for medication administration and glucometer audits.
Failure to provide appropriate respiratory care including oxygen tubing changes and adherence to oxygen orders.
Failure to provide restorative therapy and range of motion exercises as ordered.
Failure to ensure fall prevention measures including placement of fall mats.
Failure to provide enteral feedings according to physician orders.
Failure to label and store medications properly including expired medications and opened dates.
Failure to implement effective infection prevention and control program including proper PPE use, hand hygiene, COVID-19 testing, and housekeeping training.
Report Facts
Resident census: 66
Residents needing assistance with bathing: 54
Residents dependent on bathing: 12
Residents needing assistance with toileting: 58
Residents dependent on toileting: 3
Residents needing assistance with dressing: 60
Residents dependent on dressing: 4
Residents needing assistance with transfers: 35
Residents dependent on transfers: 13
Residents needing assistance with eating: 29
Residents dependent on eating: 4
Medication administration frequency: 6
Oxygen tubing change frequency: 7
Medication expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Observed wearing cloth mask below nose in droplet precaution room and not changing mask immediately |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including infection control, staffing, medication labeling |
| RCNA #2 | Restorative Certified Nurse Assistant | Interviewed regarding restorative therapy services and resident care |
| SW | Social Worker | Interviewed regarding ancillary services and grievance follow-up |
| LED | Life Enrichment Director | Interviewed regarding activity programming and resident engagement |
| MDSC | Minimum Data Set Coordinator | Observed serving meals without offering hand hygiene assistance |
| HSK #1 | Housekeeper | Observed improper cleaning practices and lack of chemical training |
| HSK #2 | Housekeeper | Observed improper cleaning practices and lack of chemical training |
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