Deficiencies (last 3 years)
Deficiencies (over 3 years)
24.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
375% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide physician-ordered medications to Resident #2.
Complaint Details
The complaint investigation found that Resident #2 missed multiple doses of Xifaxan and other medications due to the facility not having the medication available from the pharmacy. The facility did not notify the provider group when the medication was unavailable. Resident #2 and her representative reported difficulties in obtaining medications at the facility.
Findings
The facility failed to provide ordered medications, specifically Xifaxan, to Resident #2 on multiple occasions due to medication unavailability. The medication was not available from the pharmacy between 11/20/25 and 11/25/25 and again in December, resulting in missed doses. Staff interviews confirmed the medication was difficult to obtain and that the facility did not notify the provider group when doses were missed.
Deficiencies (1)
Failure to provide physician ordered medications, specifically Xifaxan, to Resident #2 due to medication unavailability.
Report Facts
Residents in sample: 14
Missed doses of Xifaxan: 5
Missed doses of Lotilaner ophthalmic solution: 6
Missed doses of Midodrine: 1
Medication supply duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding medication administration and availability of Xifaxan |
| Physician Assistant | Interviewed regarding medication procurement difficulties and notification procedures | |
| Nursing Home Administrator | NHA | Interviewed regarding medication supply and administration issues |
Inspection Report
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical service requirements and medication administration for residents, specifically focusing on medication availability and administration for Resident #2.
Findings
The facility failed to provide physician-ordered medications, including Xifaxan, to Resident #2 on multiple occasions due to medication unavailability. The facility did not notify the provider group when medications were missed, and some doses were missed despite family-provided medication.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Resident #2 missed multiple doses of physician-ordered medications due to unavailability at the facility.
Report Facts
Missed doses of Xifaxan: 7
Missed doses of Lotilaner ophthalmic solution: 6
Missed dose of Midodrine: 1
Medication supply duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Interviewed regarding medication availability and administration for Resident #2. | |
| Physician's Assistant | Interviewed about medication procurement difficulties and notification procedures. | |
| Nursing Home Administrator (NHA) | Interviewed about medication supply and administration issues. |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
Routine inspection of Cherrelyn Healthcare Center to assess compliance with regulatory requirements including resident care, infection control, and hospice services.
Findings
The facility failed to provide adequate activities for Resident #35, timely provision of eyeglasses for Resident #1, proper tube feeding administration for Resident #578, coordinated hospice care plans for Residents #169 and #12, appropriate hand hygiene opportunities for residents prior to meals, and proper use of personal protective equipment (PPE) for Resident #60 on enhanced barrier precautions.
Deficiencies (5)
F 0679: The facility failed to ensure Resident #35 received ongoing activities tailored to her needs, missing three one-to-one sessions in the past month.
F 0685: The facility failed to assist Resident #1 in obtaining new eyeglasses despite a prescription and Medicaid coverage delays.
F 0693: The facility failed to ensure Resident #578 received tube feedings as ordered, with feedings stopped early for therapy causing a two-hour daily deficit.
F 0849: The facility failed to have coordinated hospice care plans including both hospice and facility services for Residents #169 and #12.
F 0880: The facility failed to offer residents hand hygiene prior to meals and staff did not wear required PPE for Resident #60 on enhanced barrier precautions.
Report Facts
One-to-one activity sessions missed: 3
Tube feeding hours missed: 2
Feeding tube fluid amount: 501
Tube feeding volume prescribed: 1540
BIMS score: 0
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON #1 | Assistant Director of Nursing | Interviewed regarding infection control program and PPE use for Resident #60 |
| RN #2 | Registered Nurse | Interviewed about tube feeding administration for Resident #578 |
| HRN | Hospice Registered Nurse | Interviewed about hospice care coordination for Resident #169 |
| SS #3 | Social Service | Interviewed about arranging eye exams and Medicaid payment for Resident #1's glasses |
| BOM | Business Office Manager | Interviewed about Medicaid payment and billing for Resident #1's eyeglasses |
| DM | Dietary Manager | Interviewed about hand hygiene practices during meals |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including activities programming, vision and hearing services, feeding tube care, hospice services coordination, infection prevention and control, and hand hygiene practices.
Findings
The facility was found deficient in multiple areas including failure to provide adequate activities programming for Resident #35, failure to assist Resident #1 in obtaining new glasses, failure to ensure Resident #578 received feeding tube nutrition as ordered, failure to coordinate hospice care plans for Residents #169 and #12, failure to offer hand hygiene opportunities to residents prior to meals, and failure to ensure staff wore appropriate PPE for Resident #60 on enhanced barrier precautions.
Deficiencies (6)
Failed to provide ongoing activities program meeting Resident #35's needs and interests, including one-to-one activities.
Failed to assist Resident #1 in obtaining new glasses despite prescription and insurance arrangements.
Failed to ensure Resident #578 received feeding tube nutrition as ordered, with feedings stopped early and not restarted on time.
Failed to have coordinated written hospice care plans including both hospice and facility services for Residents #169 and #12.
Failed to offer residents opportunity for hand hygiene prior to meals; hand sanitizer dispensers were inaccessible and wipes unavailable.
Failed to ensure staff wore appropriate PPE (gown, gloves, mask, eye protection) for Resident #60 on enhanced barrier precautions.
Report Facts
Residents reviewed: 59
One-to-one activities sessions missed: 3
Feeding tube formula volume: 1540
Feeding tube feeding hours: 22
Feeding tube off time: 4
BIMS score: 13
BIMS score: 0
BIMS score: 0
Care conference missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON #1 | Assistant Director of Nursing | Interviewed regarding infection control program and PPE use |
| RN #2 | Registered Nurse | Interviewed about feeding tube care for Resident #578 |
| SS #3 | Social Service | Interviewed about arranging eye exams and glasses for Resident #1 |
| BOM | Business Office Manager | Interviewed about Medicaid payment and glasses procurement for Resident #1 |
| HRN | Hospice Registered Nurse | Interviewed about hospice care coordination for Resident #169 |
| SS #1 | Social Service | Interviewed about hospice referrals and care coordination |
| SS #2 | Social Service | Interviewed about care conferences scheduling for Resident #12 |
| LPN #4 | Licensed Practical Nurse | Interviewed about care plan development for Resident #12 |
| MDSC #1 | Minimum Data Set Coordinator | Interviewed about care plan coordination for Resident #12 |
| DM | Dietary Manager | Interviewed about hand hygiene practices in dining rooms |
| DA | Dietary Assistant | Interviewed about offering hand hygiene to residents |
| CNA #6 | Certified Nurse Aide | Observed and interviewed about PPE use for Resident #60 |
| CNA #7 | Certified Nurse Aide | Interviewed about PPE use for Resident #60 |
| CNA #3 | Certified Nurse Aide | Interviewed about PPE use for Resident #60 |
| LPN #5 | Licensed Practical Nurse | Interviewed about PPE use for Resident #60 |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 16, 2023
Visit Reason
Routine inspection of Cherrelyn Healthcare Center to assess compliance with regulatory requirements including resident care, medication management, food service, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide residents with dignity during dining, untimely meal delivery, lack of access to survey results, privacy violations during personal care, inadequate fall prevention and post-fall assessments, medication storage and administration issues, catheter care deficiencies, improper oxygen therapy administration, failure to provide timely behavioral health services, improper food preparation and texture modification, inadequate food storage temperatures, insufficient dishwashing sanitization, and failure to ensure hand hygiene before meals.
Deficiencies (11)
F 0550: The facility failed to provide residents dignity by using disposable cutlery and delayed meal delivery beyond posted times.
F 0577: The facility failed to make survey results accessible to residents and families for the past three years.
F 0583: The facility failed to provide privacy for Resident #151 during toileting by leaving bathroom doors open.
F 0689: The facility failed to provide adequate supervision and fall prevention for Resident #151 and failed to conduct post-fall assessments.
F 0689: The facility left medications unattended accessible to Resident #151 who wanders, and failed to assess residents #86 and #23 for self-administration of medications.
F 0689: The facility failed to follow physician orders for catheter care and failed to maintain catheter bag below bladder for Residents #101 and #111.
F 0695: The facility failed to administer oxygen therapy as ordered for Residents #92 and #411.
F 0740: The facility failed to provide timely behavioral health services and coordinate mental health care for Resident #20.
F 0761: The facility failed to properly label insulin vials and pens with open dates and maintain medication carts clean and free of loose pills.
F 0805: The facility failed to provide food prepared according to residents' prescribed diet texture orders and failed to educate Resident #103 on diet restrictions.
F 0812: The facility failed to maintain safe food storage temperatures in walk-in and unit refrigerators, failed to maintain proper dishwashing temperatures, failed to ensure proper hand hygiene during meal service, and failed to offer residents hand hygiene before meals.
Report Facts
Insulin pen open date missing: 2
Dish machine rinse temperatures below standard: 71
Walk-in refrigerator temperature: 46
Walk-in refrigerator temperature: 43
Unit refrigerator temperature: 50
Meal delivery delay: 24
Silverware ordered: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CK #1 | Cook | Named in improper hand hygiene and food handling during meal service. |
| DM | Dietary Manager | Interviewed regarding food preparation, refrigerator temperatures, and dish machine issues. |
| NHA | Nursing Home Administrator | Interviewed regarding survey results accessibility and facility operations. |
| LPN #1 | Licensed Practical Nurse | Named in medication safety and catheter care deficiencies. |
| DON | Director of Nursing | Interviewed regarding fall prevention, catheter care, oxygen therapy, and behavioral health services. |
| CNA #1 | Certified Nurse Aide | Named in privacy violation and fall incident observations. |
| LPN #3 | Licensed Practical Nurse | Named in oxygen therapy administration deficiency. |
| SSA | Social Service Assistant | Named in behavioral health services coordination. |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Aug 16, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident rights, care, safety, medication management, dietary services, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during dining, untimely meal delivery, lack of access to survey results, privacy violations during personal care, inadequate fall prevention and post-fall assessments, medication management errors including unsecured medications and improper storage, failure to follow catheter care orders, improper oxygen administration, delayed behavioral health services, improper food preparation and texture modifications, inadequate food safety practices including improper refrigeration and dishwashing temperatures, and failure to provide hand hygiene opportunities to residents before meals.
Deficiencies (12)
Failure to provide residents with dignity and respect during dining by using disposable cutlery and delayed meal delivery.
Failure to provide residents access to survey results from previous annual and complaint surveys.
Failure to ensure privacy for a resident during toileting and personal care.
Failure to provide adequate supervision and post-fall assessments for a resident with multiple falls and unsafe environment.
Failure to secure medications and ensure proper medication self-administration assessments for residents.
Failure to follow physician orders for catheter care including proper positioning of catheter bags and catheter flushes.
Failure to administer oxygen therapy according to physician orders for two residents.
Failure to provide timely behavioral health services as recommended for a resident with mental health needs.
Failure to properly label and store insulin and maintain medication carts clean and free of loose pills.
Failure to provide meals prepared according to prescribed diet texture orders and failure to educate residents on diet restrictions.
Failure to maintain proper food safety including refrigeration temperatures, dishwashing temperatures, and hand hygiene before meals.
Failure of dietary staff to perform proper hand hygiene and glove use while plating and serving meals.
Report Facts
Insulin pen open date missing: 2
Dish machine rinse temperatures below standard: 71
Walk-in refrigerator temperature: 46
Walk-in refrigerator temperature: 43
Unit refrigerator temperature: 50
Meal delivery delay: 24
Silverware ordered: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CK #1 | Cook | Named in improper hand hygiene and food handling during meal service. |
| DA #1 | Dietary Aide | Named in silverware shortage and meal delivery delay. |
| DM | Dietary Manager | Named in multiple dietary deficiencies including meal preparation and food safety. |
| LPN #1 | Licensed Practical Nurse | Named in medication and catheter care deficiencies. |
| DON | Director of Nursing | Named in oversight of multiple care and safety deficiencies. |
| NHA | Nursing Home Administrator | Named in oversight and interviews related to multiple deficiencies. |
| SSA | Social Service Assistant | Named in behavioral health service provision. |
| LPN #2 | Licensed Practical Nurse | Named in medication self-administration assessment and medication removal. |
| LPN #3 | Licensed Practical Nurse | Named in oxygen therapy administration deficiency. |
| CNA #4 | Certified Nurse Aide | Named in catheter care and fall prevention deficiencies. |
Inspection Report
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the provision of a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the availability of clean washcloths and hand towels in resident rooms.
Findings
The facility failed to ensure that staff provided clean washcloths and hand towels to residents in their rooms on two of six halls. Observations, resident interviews, and staff interviews confirmed that many rooms lacked these linens during the day, although linens were stocked during the night shift and available in linen closets and carts.
Deficiencies (1)
Failure to provide clean washcloths and hand towels to residents in their rooms on two of six halls.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding linen provision and use during morning care. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about night shift responsibilities for stocking linens. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed about responsibilities for stocking linens in resident bathrooms. |
| Certified Nurse Aide #4 | Certified Nurse Aide | Interviewed about night shift duties for stocking linens. |
| Director of Nursing | Director of Nursing | Interviewed about linen stocking policies and resident supplies. |
Inspection Report
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the provision of a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the availability of clean washcloths and hand towels in resident rooms.
Findings
The facility failed to ensure that staff provided clean washcloths and hand towels to residents in their rooms on two of six halls. Observations, resident interviews, and staff interviews confirmed inconsistent availability of these linens during the day, although linens were stocked during the night shift.
Deficiencies (1)
F 0584: The facility failed to provide a policy regarding the provision of clean washcloths and towels for residents. Staff did not consistently provide clean washcloths and hand towels in resident bathrooms during the day shift.
Inspection Report
Census: 168
Deficiencies: 19
Date: Jun 15, 2022
Visit Reason
The inspection was conducted to assess compliance with state and federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident rights, abuse prevention, care and treatment of residents, infection control, staffing, and quality assurance. Specific failures included inadequate pain management, insufficient staffing, failure to prevent resident-to-resident abuse, inadequate wound care, failure to provide timely and appropriate respiratory care, and lack of proper infection control practices.
Deficiencies (19)
Resident #143 was not provided a physician order for code status and lacked a medical order for scope of treatment (MOST) form, violating resident rights to request or refuse treatment.
Resident #87's grievances about missing personal items were not documented or resolved promptly, violating the resident's right to voice grievances.
Resident #70 was verbally abused and threatened by Resident #120, and the facility failed to protect Resident #70 from further abuse or report the incident as required.
Resident #266 and other dependent residents did not receive timely assistance with activities of daily living including bathing, toileting, and positioning, resulting in physical and psychosocial harm.
Resident #407 did not have a physician order for oxygen therapy, and the resident experienced respiratory distress due to kinked oxygen tubing that was not promptly addressed by staff.
Resident #61 developed a facility-acquired stage 3 pressure ulcer on the coccyx that was not assessed or treated timely, resulting in wound progression.
Resident #264 sustained second degree burns to the face and hypoxemia after smoking while on oxygen therapy, due to lack of appropriate supervision and safety interventions.
Resident #134 had an indwelling catheter in place without a physician order or catheter care orders.
Resident #70 used a CPAP machine without a physician order or care plan specifying settings and cleaning instructions.
Resident #147 had unresolved right hand and forearm pain and edema with inadequate pain management and lack of care plan interventions.
Resident #262 with dementia was not provided meaningful activities or one-to-one visits and was frequently observed wandering unsupervised.
Resident #55 was not provided timely toileting care, was missing a cell phone important for socialization, and had limited activity engagement.
Resident #44's insulin pen was administered without priming, risking incorrect dosing.
Resident #206 missed routine morning medications due to pharmacy delivery delays and lack of use of emergency medication supplies.
Resident #24 received a double dose of pain medication after a missed dose without physician notification.
Resident rooms were not cleaned appropriately, including use of contaminated cloths and improper cleaning sequence, risking infection transmission.
Staff failed to don and doff personal protective equipment (PPE) correctly when entering and exiting COVID-19 isolation rooms, risking infection spread.
Facility failed to notify residents and families of a COVID-19 outbreak affecting four residents and four staff within required timeframes.
Facility failed to provide annual abuse, neglect, exploitation, and dementia management training to nursing staff since 2017.
Report Facts
Residents needing assistance with bathing: 158
Residents dependent on staff for toileting: 6
Residents needing assistance with dressing: 164
Residents dependent on staff for dressing: 6
Residents needing assistance with transfers: 127
Residents dependent on staff for transfers: 32
Residents needing assistance with eating: 47
Residents dependent on staff for eating: 5
Residents receiving preventative skin care: 168
Residents requiring special respiratory treatments: 61
Residents with behavioral health care needs: 34
Staffing hours shortfall on 5/6/22: 82
Staffing hours shortfall on 5/7/22: 116.4
Staffing hours shortfall on 5/8/22: 162.4
Staffing hours shortfall on 5/9/22: 210.4
Staffing hours shortfall on 5/10/22: 218.4
Staffing hours shortfall on 5/11/22: 264.2
Staffing hours shortfall on 5/12/22: 278.6
Staffing hours shortfall on 5/13/22: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Administered insulin pen without priming |
| LPN #6 | Licensed Practical Nurse | Administered medications late, did not check Omnicell |
| UM #1 | Unit Manager | Notified physician about medication delay, did not retrieve meds from Omnicell |
| DON | Director of Nursing | Acknowledged multiple care failures and lack of staff training |
| NHA | Nursing Home Administrator | Provided staffing formula and interviewed about staffing and quality |
| HSKS | Housekeeping Supervisor | Observed improper cleaning practices |
| RN #4 | Registered Nurse | Documented resident verbal abuse incident, did not report to NHA |
| RN #5 | Registered Nurse | Acknowledged incomplete CPAP orders and cleaning instructions |
| LPN #9 | Licensed Practical Nurse | Described CPAP cleaning procedure |
| IP | Infection Preventionist | Reported lack of recent PPE training |
| SSD | Social Services Director | Reported lack of hospice communication and resident phone missing |
| AD | Activity Director | Reported lack of one-to-one visits and inaccurate activity documentation |
| AA #1 | Activity Assistant | Observed leaving reading materials without engagement |
| LPN #8 | Licensed Practical Nurse | Did not complete wound treatment |
| NP #1 | Nurse Practitioner | Evaluated resident hand edema and ordered ultrasound |
| LPN #3 | Licensed Practical Nurse | Reported staffing shortages and weekend CNA shortage |
| CNA #6 | Certified Nursing Aide | Reported insufficient staffing and inability to meet all resident needs |
| LPN #7 | Licensed Practical Nurse | Observed oxygen liter flow not matching physician order |
| LPN #4 | Registered Nurse | Documented verbal abuse incident but did not report as abuse |
| LPN #1 | Licensed Practical Nurse | Unaware of catheter duration and lack of orders |
| LPN #2 | Licensed Practical Nurse | Reported lack of hospice communication and documentation |
| LPN #10 | Licensed Practical Nurse | Described nurse responsibilities for change in condition |
| LPN #11 | Licensed Practical Nurse | Described nurse responsibilities for change in condition |
| LPN #18 | Certified Nursing Aide | Reported improper CPAP cleaning and lack of supplies |
| LPN #20 | Certified Nursing Aide | Reported improper CPAP cleaning and lack of supplies |
| HSKP #3 | Housekeeper | Observed improper cleaning and PPE use |
| AA #2 | Activity Assistant | Observed entering isolation room without proper PPE |
| RN #1 | Registered Nurse | Observed wearing same N95 mask between isolation and non-isolation rooms |
| LPN #6 | Licensed Practical Nurse | Observed wearing same N95 mask between isolation and non-isolation rooms |
| LPN #5 | Licensed Practical Nurse | Observed wearing mask under chin while administering medications |
| CNA #14 | Certified Nursing Aide | Observed wearing mask under chin in hallways |
| UM #2 | Unit Manager | Acknowledged resident had catheter without orders |
| LPN #8 | Licensed Practical Nurse | Did not complete wound treatment |
| LPN #9 | Licensed Practical Nurse | Described CPAP cleaning procedure |
| RN #5 | Registered Nurse | Acknowledged incomplete CPAP orders and cleaning instructions |
| LPN #4 | Registered Nurse | Documented verbal abuse incident but did not report as abuse |
| UM #1 | Unit Manager | Notified physician about resident pain and wound concerns |
| DON | Director of Nursing | Acknowledged multiple care failures and lack of staff training |
| NHA | Nursing Home Administrator | Provided staffing formula and interviewed about staffing and quality |
| SSD | Social Services Director | Reported lack of hospice communication and resident phone missing |
| IP | Infection Preventionist | Reported lack of recent PPE training |
Inspection Report
Routine
Census: 168
Deficiencies: 17
Date: Jun 15, 2022
Visit Reason
Routine state inspection survey conducted to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident rights, inadequate grievance resolution, failure to protect residents from abuse, insufficient assistance with activities of daily living, failure to identify and report changes in resident condition, inadequate wound care, unsafe smoking practices, medication errors, insufficient staffing, lack of staff competency training, inadequate dementia care, infection control lapses, and failure to notify residents and families of COVID-19 outbreaks.
Deficiencies (17)
Failure to ensure resident rights related to advance directives and code status orders.
Failure to resolve resident grievances timely and document investigations.
Failure to protect resident from verbal abuse and threats by another resident.
Failure to provide timely and adequate assistance with activities of daily living including bathing, toileting, positioning, and transfers.
Failure to assess and treat changes in resident condition leading to hospitalizations.
Failure to provide adequate wound care and timely assessment leading to worsening pressure ulcers.
Failure to prevent resident injury from unsafe smoking while on oxygen therapy resulting in second degree burns.
Failure to have physician orders and catheter care for resident with indwelling catheter.
Failure to provide complete and accurate respiratory care including oxygen and CPAP therapy orders and care plans.
Failure to provide effective pain management and monitoring for resident with chronic pain and edema.
Failure to provide sufficient nursing staff to meet resident care needs based on acuity and census.
Failure to ensure nursing staff and aides received required annual competency training and skills validation.
Failure to provide adequate dementia care and meaningful activities including one-to-one visits for residents with cognitive impairment.
Failure to prevent medication errors including insulin pen priming, missed medications, and double dosing.
Failure to clean resident rooms appropriately and follow infection control practices including proper donning and doffing of PPE and mask wearing.
Failure to notify residents and families timely of COVID-19 outbreak in the facility.
Failure to provide staff training on abuse, neglect, exploitation, and dementia care annually.
Report Facts
Resident census: 168
Staffing shortage hours: 82
Staffing shortage hours: 116.4
Staffing shortage hours: 162.4
Staffing shortage hours: 210.4
Staffing shortage hours: 218.4
Staffing shortage hours: 264.2
Staffing shortage hours: 278.6
Staffing shortage hours: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Administered insulin pen without priming; failed to administer medications to Resident #206 on 6/8/22 |
| LPN #6 | Licensed Practical Nurse | Failed to complete wound treatment on Resident #143 on 6/8/22; observed wearing same N95 mask between COVID and non-COVID rooms |
| RN #4 | Registered Nurse Unit Manager | Documented resident to resident verbal abuse incident; failed to report abuse; failed to separate residents |
| DON | Director of Nursing | Acknowledged multiple failures including wound care, abuse reporting, staffing, and pain management |
| NHA | Nursing Home Administrator | Provided staffing formula and interviewed about staffing shortages and quality concerns |
| IP | Infection Preventionist | Reported lack of recent PPE training and improper PPE use |
| SSD | Social Services Director | Reported failure to document and communicate hospice visits; reported resident concerns about staffing and care |
| HSKS | Housekeeping Supervisor | Observed improper cleaning practices and provided training plan |
| LPN #9 | Licensed Practical Nurse | Reported lack of CPAP cleaning knowledge and incomplete CPAP orders |
| RN #5 | Registered Nurse | Reported lack of CPAP cleaning knowledge and incomplete CPAP orders |
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