Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
281% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
39% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 18, 2025
Visit Reason
The inspection was conducted to investigate and document a significant medication error involving warfarin administration at LA Villa Grande Care Center.
Findings
The facility failed to prevent a significant medication error when Resident #8 received warfarin twice daily instead of once daily as ordered, and failed to properly document and monitor INR levels. This error placed the resident at risk for serious harm, though no adverse outcome was ultimately reported.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors. Resident #8 received warfarin twice daily instead of once daily due to incomplete physician orders and inadequate monitoring of INR levels.
Report Facts
Residents reviewed for medication errors: 3
Resident #8 warfarin dosing period: 13
INR test results: 4.5
Correction date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding warfarin order verification and monitoring procedures. |
| Director of Nursing | DON | Provided plan of correction and described auditing and education efforts post-error. |
| Staff Development Coordinator | SDC | Assisted DON in providing education on warfarin policy to nursing staff. |
| Nurse Practitioner | NP | Interviewed about warfarin administration protocols and monitoring. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 18, 2025
Visit Reason
The inspection was conducted due to a significant medication error involving warfarin administration at LA Villa Grande Care Center, resulting in immediate jeopardy to resident health or safety.
Findings
The facility failed to prevent a significant medication error when Resident #8 received warfarin twice daily instead of once daily as ordered, and failed to properly document and monitor INR levels, placing the resident at risk for serious harm. The facility corrected the deficient practice prior to the onsite investigation and implemented a plan of correction including staff education, audits, and updated procedures.
Deficiencies (1)
Failure to prevent a significant medication error involving warfarin administration resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents reviewed for medication errors: 3
Residents affected: 1
Warfarin doses administered: 2
INR levels: 4.5
Correction date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding warfarin order verification and monitoring practices |
| Director of Nursing | DON | Provided plan of correction and described auditing and education efforts |
| Staff Development Coordinator | SDC | Provided education on warfarin policy to nursing staff |
| Nurse Practitioner | NP | Interviewed about warfarin administration protocol and monitoring |
Inspection Report
Routine
Deficiencies: 9
Date: May 22, 2025
Visit Reason
Routine inspection of LA Villa Grande Care Center to assess compliance with regulatory requirements including medication administration, resident safety, abuse prevention, psychotropic medication use, restorative care, food service, and infection control.
Findings
The facility failed to ensure appropriate assessment and physician orders for medication self-administration, maintain resident safety to prevent falls and abuse, properly manage psychotropic medications, provide consistent restorative care, serve palatable and appropriately tempered food, and maintain infection control practices including hand hygiene and use of personal protective equipment.
Deficiencies (9)
F554: The facility failed to ensure Resident #15 was assessed and had a physician's order for self-administration of medications and documented medication administration accurately.
F574: The facility failed to post State Survey Agency contact information in a manner accessible and understandable to all residents.
F600: The facility failed to prevent resident-to-resident abuse involving Residents #68, #71, and #65, and failed to implement timely and effective interventions.
F605: The facility failed to ensure appropriate physician rationale and behavior documentation for psychotropic medication use for Residents #48, #61, #5, and #387.
F688: The facility failed to ensure Resident #80 was consistently provided services through the walk-to-dine program to maintain ambulation status.
F689: The facility failed to identify and implement timely interventions to prevent falls and injuries for Resident #28, who sustained multiple falls and injuries including a head laceration requiring hospital care.
F759: The facility's medication error rate was 7.69%, exceeding the allowed 5%, including errors in medication administration for Resident #15.
F804: The facility failed to consistently serve food that was palatable and at appropriate temperatures, with observations of lukewarm meals and poor food quality.
F880: The facility failed to ensure consistent hand hygiene practices when providing meal assistance and failed to implement infection control practices including use of personal protective equipment for residents on enhanced barrier precautions.
Report Facts
Medication error rate: 7.69
Resident sample size: 37
Fall risk score: 12
Fall risk score: 23
Temperature: 111.6
Temperature: 103
Temperature: 109.5
Temperature: 114.3
Temperature: 67.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in medication error finding for Resident #15 |
| RN #1 | Registered Nurse | Interviewed regarding medication administration and walk-to-dine program |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication administration, falls, and infection control |
| NHA | Nursing Home Administrator | Interviewed regarding multiple findings including falls, medication errors, and infection control |
| CC | Corporate Consultant | Interviewed regarding multiple findings including falls, medication errors, and infection control |
| DOR | Director of Rehabilitation | Interviewed regarding walk-to-dine program and physical therapy for Resident #80 |
| CNA #3 | Certified Nurse Aide | Interviewed regarding walk-to-dine program and infection control |
| CNA #6 | Certified Nurse Aide | Interviewed regarding infection control and PPE use |
| CNA #13 | Certified Nurse Aide | Observed and interviewed regarding hand hygiene during meal assistance |
| CNA #14 | Certified Nurse Aide | Observed and interviewed regarding hand hygiene during meal assistance |
| Consultant Pharmacist | Interviewed regarding medication errors and psychotropic medication use | |
| IP | Infection Preventionist | Interviewed regarding infection control practices and education |
| DM | Dietary Manager | Interviewed regarding food temperature and palatability issues |
| RD | Registered Dietitian | Interviewed regarding food temperature and palatability |
| Consultant Pharmacist | Interviewed regarding psychotropic medication use and recommendations |
Inspection Report
Routine
Census: 37
Deficiencies: 9
Date: May 22, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident rights, abuse prevention, psychotropic medication use, restorative care, fall prevention, medication error rates, food service quality, and infection control.
Findings
The facility was found deficient in multiple areas including failure to assess resident self-administration of medications, inadequate posting of State Survey Agency contact information, failure to prevent resident-to-resident abuse, inappropriate use and documentation of psychotropic medications, failure to provide consistent restorative ambulation services, inadequate fall prevention interventions resulting in multiple falls with injury, medication administration errors exceeding acceptable rates, serving food at inappropriate temperatures, and lapses in infection prevention practices including hand hygiene and use of personal protective equipment.
Deficiencies (9)
Failed to ensure assessment and physician order for self-administration of medications for Resident #15.
Failed to post State Survey Agency contact information in a manner accessible and understandable to residents.
Failed to prevent resident-to-resident abuse involving Residents #68, #71, and #65.
Failed to ensure appropriate use and documentation of psychotropic medications for Residents #48, #61, #5, and #387.
Failed to provide consistent restorative nursing services through the walk-to-dine program for Resident #80.
Failed to provide adequate supervision and timely interventions to prevent falls for Resident #28, resulting in multiple falls and injury.
Medication error rate was 7.69%, exceeding the acceptable rate of less than 5%. Errors included incorrect medication administration and documentation for Resident #15.
Failed to ensure food was served at palatable temperatures and with acceptable taste and texture.
Failed to ensure consistent hand hygiene and use of personal protective equipment (PPE) when providing meal assistance and direct care to residents, including failure to don PPE for residents on enhanced barrier precautions.
Report Facts
Medication error rate: 7.69
Residents affected by medication errors: 1
Residents affected by abuse: 2
Falls by Resident #28: 3
BIMS scores: 14
BIMS scores: 6
BIMS scores: 3
Temperature of Salisbury steak: 111.6
Temperature of oven-fried potatoes: 103
Temperature of spinach: 109.5
Temperature of chicken and rice stew: 114.3
Temperature of coconut pie: 67.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in medication error finding related to Resident #15 |
| RN #1 | Registered Nurse | Interviewed regarding medication self-administration and walk-to-dine program |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication administration, fall prevention, and infection control |
| NHA | Nursing Home Administrator | Interviewed regarding multiple findings including policy, fall prevention, and infection control |
| CC | Corporate Consultant | Interviewed regarding multiple findings including fall prevention and infection control |
| IP | Infection Preventionist | Interviewed regarding infection control practices and education |
| CNA #13 | Certified Nurse Aide | Observed and interviewed regarding hand hygiene lapses during meal assistance |
| CNA #14 | Certified Nurse Aide | Observed and interviewed regarding hand hygiene lapses during meal assistance |
| DOR | Director of Rehabilitation | Interviewed regarding walk-to-dine program and physical therapy communication |
| DM | Dietary Manager | Interviewed regarding food temperature and palatability concerns |
| Consultant Pharmacist | Interviewed regarding medication errors and psychotropic medication use |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 8, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, food safety, and regulatory requirements at LA Villa Grande Care Center.
Findings
The facility failed to monitor and manage Resident #9's fluid intake effectively, resulting in hospitalization for fluid overload. Resident #3 was not provided education on diabetic diet adherence and her care plan was not updated to document refusals. The kitchen failed to store and handle food safely, including moldy produce, undated food items, dented cans, and poor hand hygiene practices among staff.
Deficiencies (2)
F 0658: The facility failed to ensure Resident #9's fluid intake was monitored and managed effectively, leading to hospitalization for fluid overload. Resident #3 was not educated on diabetic diet risks and her care plan did not document refusals to comply with the diet.
F 0812: The facility failed to store food safely, including use of dented cans and moldy, undated produce. Ready-to-eat foods were handled unsanitarily, with staff failing to perform hand hygiene and improper glove use during meal preparation.
Report Facts
Resident weight gain: 35
Fluid intake exceedances: 9
Fluid intake exceedances: 7
Fluid intake exceedances: 2
Moldy strawberry containers: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Interviewed regarding Resident #3's diet adherence and family food brought in. |
| Licensed Practical Nurse #2 | LPN | Interviewed about documentation and communication of diet refusals. |
| Registered Nurse #2 | RN | Interviewed about education efforts for diet adherence. |
| Licensed Practical Nurse #1 | LPN | Interviewed about physician notification and documentation of diet refusals. |
| Registered Dietitian | RD | Interviewed about diet adherence education, fluid restriction orders, and kitchen oversight. |
| Director of Nursing | DON | Interviewed about expectations for diet adherence education and fluid restriction orders. |
| Dietary Manager | DM | Interviewed about food storage, dented cans, moldy produce, and hand hygiene re-education. |
| Cook #1 | CK | Interviewed about food preparation and handling of produce. |
| Cook #2 | CK | Interviewed about produce turnover and glove use during meal preparation. |
| Registered Nurse #1 | RN | Interviewed as infection preventionist about hand hygiene audits. |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 8, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care and food safety practices at LA Villa Grande Care Center.
Findings
The facility failed to ensure professional standards of care related to fluid intake monitoring and diabetic diet adherence for two residents, resulting in minimal harm. Additionally, the kitchen failed to maintain sanitary food storage and handling practices, including use of dented cans, moldy produce, undated food items, and improper hand hygiene by staff.
Deficiencies (3)
Failed to monitor and manage Resident #9's fluid intake effectively, resulting in hospitalization for fluid overload.
Failed to provide Resident #3 with education on risks of not following diabetic diet and failed to update care plan to document refusals.
Failed to store, prepare, distribute, and serve food in a sanitary manner, including use of dented cans, moldy and undated produce, and improper hand hygiene during food handling.
Report Facts
Resident weight gain: 35
Fluid intake exceedances: 9
Fluid intake exceedances: 7
Fluid intake exceedances: 2
Physician fluid restriction order: 2500
Physician fluid restriction order: 3000
MDS BIMS score: 11
MDS BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Interviewed regarding Resident #3's diet adherence and family food brought in. |
| Licensed Practical Nurse #2 | LPN | Interviewed about documentation and communication of diet refusals. |
| Registered Nurse #2 | RN | Interviewed about education efforts for diet adherence. |
| Licensed Practical Nurse #1 | LPN | Interviewed about physician notification and documentation of diet refusals. |
| Registered Dietitian | RD | Interviewed about diet adherence, fluid restriction orders, and kitchen oversight. |
| Director of Nursing | DON | Interviewed about expectations for diet adherence education and fluid restriction orders. |
| Dietary Manager | DM | Interviewed about food storage, handling, and removal of moldy/dented items. |
| Cook #1 | CK | Observed and interviewed regarding food preparation and handling. |
| Cook #2 | CK | Observed and interviewed regarding glove use and food handling. |
| Registered Nurse #1 | RN | Infection preventionist interviewed about hand hygiene training and audits. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
Annual inspection survey of LA Villa Grande Care Center conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for LA Villa Grande Care Center, summarizing the findings of a regulatory survey completed on 2024-02-12.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 16
Date: Nov 16, 2023
Visit Reason
Routine state inspection survey of LA Villa Grande Care Center to assess compliance with regulatory requirements including resident care, infection control, dietary services, and facility operations.
Findings
The facility had multiple deficiencies including failure to timely address resident grievances, inaccurate resident assessments, inadequate infection control practices, insufficient staffing to meet resident needs, delayed meal service, improper food handling and storage, incomplete vaccination administration, malfunctioning call light system, and improper wound care procedures.
Deficiencies (16)
F 0565: Facility failed to follow up and resolve resident grievances timely, including a complaint of derogatory name-calling by staff and concerns about cold food temperatures.
F 0578: Facility failed to ensure Resident #11's proxy complied with legal requirements for life-saving treatment decisions, including artificial nutrition and hydration.
F 0625: Facility failed to inform Resident #56 or responsible party in writing of the bed hold policy prior to discharge or transfer.
F 0626: Facility failed to permit Resident #86 to return after hospitalization due to inadequate assessment and refusal to accept resident back despite stability.
F 0641: Facility failed to accurately document residents' status on minimum data set (MDS) assessments for transfer assistance, pneumococcal vaccination, and antidepressant use for four residents.
F 0676: Facility failed to provide Resident #52 with adaptive equipment to maintain ability to feed himself, despite documented feeding difficulties.
F 0685: Facility failed to ensure Resident #71 was assisted to see an audiologist despite documented hearing loss and resident complaint.
F 0686: Facility failed to prevent pressure injuries for Resident #83 by not implementing timely interventions to protect heels, resulting in worsening unstageable pressure injuries.
F 0725: Facility failed to provide sufficient nursing staff to meet resident needs in a timely manner, resulting in prolonged call light response times up to 74 minutes and resident reports of delayed assistance.
F 0802: Facility failed to employ sufficient dietary staff and provide adequate training, contributing to prolonged meal wait times and resident dissatisfaction.
F 0808: Facility failed to adequately thicken Resident #52's liquids per physician order, including serving liquids before thickening was complete and failing to provide thickened water at bedside.
F 0812: Facility failed to store, prepare, distribute, and serve food in a sanitary manner, including improper refrigerator temperature monitoring, unclean kitchen surfaces, improper storage of health shakes, and overflowing trash.
F 0847: Facility failed to thoroughly and accurately explain binding arbitration agreements to residents #189 and #190, including the right to rescind within 90 days and the legal implications of arbitration.
F 0880: Facility failed to maintain an infection control program, including failure to provide hand hygiene opportunities to residents before meals, improper hand hygiene and glove use by staff during wound care, and failure to use appropriate personal protective equipment.
F 0919: Facility failed to ensure Resident #83's restroom call light was functioning properly and failed to timely repair the call light after staff became aware of the malfunction.
F 0883: Facility failed to offer pneumococcal vaccinations upon admission or additional doses as recommended, and failed to administer annual flu vaccinations to several residents.
Report Facts
Call light response time (minutes): 74
Pressure injury size (cm): 12.2
Pressure injury size (cm): 11.8
Pressure injury size (cm): 5
Pressure injury size (cm): 3.9
Pressure injury size (cm): 2.7
Pressure injury size (cm): 2.5
Pneumococcal vaccination consent date: Aug 19, 2022
Pneumococcal vaccination consent date: May 25, 2022
Pneumococcal vaccination consent date: Nov 1, 2021
Flu vaccination consent date: Jun 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in thickened liquid preparation and administration observation |
| ADON | Assistant Director of Nursing | Named in wound care observation and call light incident |
| DM | Dietary Manager | Named in dietary staffing and food service interviews |
| CSC | Central Supply Clerk | Named in arbitration agreement explanation |
| MSD | Maintenance Service Director | Named in call light repair and kitchen maintenance |
Inspection Report
Routine
Deficiencies: 16
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, infection control, dietary services, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to timely and properly address resident grievances, inaccurate resident assessments, inadequate infection control practices, insufficient nursing and dietary staffing, improper food handling and storage, failure to provide timely call light responses, and incomplete resident immunization documentation. Specific issues included unresolved resident grievances, inaccurate MDS documentation, delayed meal service, improper wound care techniques, and malfunctioning call light systems.
Deficiencies (16)
Failure to follow up on resident grievances in a timely and effective manner.
Failure to ensure residents' rights to formulate advance directives and proper proxy decision making.
Failure to inform resident or representative in writing of bed hold policy upon hospital transfer.
Failure to permit resident to return to facility after hospitalization due to inadequate assessment and communication.
Failure to ensure accurate resident assessments on MDS including transfer status, vaccination status, and medication use.
Failure to provide adaptive equipment to maintain resident's ability to feed himself.
Failure to assist resident in gaining access to audiology services despite hearing impairment.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including timely interventions and proper wound care techniques.
Failure to provide sufficient nursing staff to meet resident needs and timely answer call lights.
Failure to provide sufficient dietary and food and nutrition staff leading to prolonged meal wait times and resident dissatisfaction.
Failure to ensure therapeutic diets are prescribed and implemented correctly, including proper thickening of liquids.
Failure to store, prepare, distribute, and serve food in a sanitary manner, including improper food temperatures, unclean kitchen surfaces, and improper storage of health shakes.
Failure to implement policies and procedures for flu and pneumococcal vaccinations, resulting in residents not being offered or receiving vaccinations timely.
Failure to ensure a working call system in resident bathrooms and timely repair of malfunctioning call lights.
Failure to ensure residents were provided opportunity for hand hygiene before meals and staff performed hand hygiene between tasks; improper wound care infection control practices.
Failure to thoroughly and accurately explain binding arbitration agreements to residents and representatives, including right to rescind.
Report Facts
Call light response times: 22
Pressure injury size: 12.2
Pressure injury size: 11.8
Pressure injury size: 7.1
Pressure injury size: 5
Pressure injury size: 5
Pressure injury size: 3.9
Pressure injury size: 2
Pressure injury size: 2.4
Pressure injury size: 2
Pressure injury size: 2.1
Pressure injury size: 1.5
Pressure injury size: 2.5
Pressure injury size: 2.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in thickened liquid preparation and administration observation and interview. |
| ADON | Assistant Director of Nursing | Named in wound care observation and interview, and call light system issue. |
| DM | Dietary Manager | Named in dietary staffing and food service interviews and observations. |
| CNA #2 | Certified Nurse Aide | Named in feeding assistance and thickened liquid awareness. |
| CNA #3 | Certified Nurse Aide | Named in dietary service and thickened liquid preparation interviews. |
| LPN #2 | Licensed Practical Nurse | Named in thickened liquid preparation interview. |
| LPN #3 | Licensed Practical Nurse | Named in thickened liquid preparation interview. |
| IP | Infection Preventionist | Named in infection control policy and practice interview. |
| MSD | Maintenance Service Director | Named in call light system and kitchen maintenance interviews. |
| CSC | Central Supply Clerk | Named in arbitration agreement explanation interview. |
| ROM | Regional Operations Manager | Named in arbitration agreement and resident return interviews. |
| NHA | Nursing Home Administrator | Named in arbitration agreement and call light system interviews. |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 19, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program and compliance with infection control policies.
Findings
The facility failed to maintain an effective infection prevention and control program, including inadequate hand hygiene practices by housekeeping staff and failure to disinfect shared equipment between resident use. Observations, record reviews, and staff interviews confirmed these deficiencies.
Deficiencies (1)
F 0880: The facility failed to ensure high touch surfaces were not potentially cross contaminated, consistent hand hygiene was performed between glove changes, and shared equipment was wiped down between resident use.
Report Facts
COVID positive residents: 23
COVID positive staff: Multiple positive staff during the facility outbreak between 3/22/23 and 5/1/23 (exact number not stated)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK #1 | Housekeeper | Observed repeatedly failing to perform hand hygiene between glove changes and not wiping down shared equipment properly |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding shared equipment disinfection practices and observed not cleaning transfer device between resident use |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding shared equipment disinfection practices and observed not cleaning transfer device between resident use |
| IP | Infection Preventionist | Interviewed about infection control practices, hand hygiene audits, and COVID outbreak |
| HKD | Housekeeping Director | Interviewed about housekeeping training and cleaning protocols |
| NHA | Nursing Home Administrator | Interviewed about facility infection control education and response |
| DON | Director of Nursing | Interviewed about facility infection control education and response |
| RN #1 | Registered Nurse | Interviewed about importance of hand hygiene to prevent infection spread |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 19, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, focusing on compliance with infection control policies and procedures.
Findings
The facility failed to maintain an effective infection prevention and control program, including inadequate hand hygiene practices by housekeeping staff, potential cross-contamination of high-touch surfaces, and inconsistent cleaning of shared equipment such as transfer devices.
Deficiencies (3)
High touch surface areas were not potentially cross contaminated.
Consistent hand hygiene was not performed between doffing and donning gloves.
Shared equipment, specifically transfer devices, was not consistently wiped down between resident use.
Report Facts
Residents affected: Some
COVID positive residents: 23
COVID outbreak dates: Outbreak period from 3/22/23 to 5/1/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Observed performing cleaning with inadequate hand hygiene and cross-contamination practices |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding hand hygiene importance |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding shared equipment disinfection practices |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding shared equipment disinfection practices |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control training, audits, and COVID outbreak |
| Housekeeping Director | Housekeeping Director | Interviewed about staff training and cleaning procedures |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about ongoing staff education on infection control |
| Director of Nursing | Director of Nursing | Interviewed about ongoing staff education on infection control |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #1, who required two-person assistance but was provided care by a single CNA, resulting in injury.
Complaint Details
The investigation was complaint-driven, focusing on a fall incident involving Resident #1. The complaint was substantiated as the facility failed to provide required two-person assistance, leading to the resident's fall and injury.
Findings
The facility failed to ensure adequate supervision and assistance for Resident #1, who required two-person assistance for personal cares. A CNA provided care alone, leading to the resident falling out of bed and sustaining bilateral femur fractures and other injuries. Staff interviews and records confirmed the resident's care needs and the failure to follow care plans.
Deficiencies (2)
F 0689: The facility failed to ensure adequate supervision and two-person assistance for Resident #1 during personal cares, resulting in a fall and serious injury. Staff did not follow care plans requiring two-person assistance despite resident needs and documented risks.
One of four staff members audited did not know how to access the care plan and required a demonstration of the process.
Report Facts
Residents affected: 1
Staff members audited: 4
Interdisciplinary team members: 11
Staff signatures: 25
Resident's BIMS score: 14
Resident hospital stay duration: 14
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #1, who required two-person assistance but was provided care by a single CNA, resulting in injury.
Complaint Details
The visit was complaint-related due to a fall incident involving Resident #1 on 12/30/22. The complaint was substantiated as the facility failed to provide required two-person assistance, resulting in the resident falling out of bed and sustaining serious injuries.
Findings
The facility failed to ensure adequate supervision and assistance to prevent accidents for Resident #1, who fell from bed due to CNA #4 providing care alone despite care plans requiring two-person assistance. The fall caused serious injuries including bilateral femur fractures and hematoma. Staff interviews and record reviews confirmed the failure to follow care plans and proper procedures.
Deficiencies (4)
Failed to ensure certified nurse aide (CNA) #4 followed proper procedure while providing cares to Resident #1 and ensure the resident was safe
Failed to implement two-person assistance when providing cares to Resident #1, which was identified as a resident need on their minimum data set (MDS) assessment
Failed to implement a care-planned intervention to provide two-person assistance when providing cares to Resident #1
One of the four staff members audited did not know how to access the care plan and required a demonstration of the process
Report Facts
Residents reviewed for falls: 3
Sample residents: 8
Resident #1 BIMS score: 14
Resident #1 hospital stay duration: 14
Staff members assisting Resident #1 after fall: 4
Interdisciplinary team members: 11
Staff signatures on attendance record: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Named in deficiency for providing care alone to Resident #1 resulting in fall |
| RN #3 | Registered Nurse | Interviewed regarding Resident #1 care and fall incident |
| Medical Director | Medical Director | Interviewed about Resident #1 care requirements and safety |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding MDS assessment and care plan compliance |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Provided facility policy and interviewed about care plan and staffing |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed about staffing and incident details |
| Restorative Certified Nurse Aide #1 | Restorative Certified Nurse Aide (RCNA) | Interviewed about care procedures and resident needs |
| CNA #3 | Certified Nurse Aide | Interviewed about care routines and training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted due to complaints regarding resident-to-resident physical abuse and inadequate dementia care services at the facility.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident abuse by Resident #2 towards Residents #3, #4, #5, and #6. The facility failed to effectively implement supervision and person-centered care approaches to prevent these incidents.
Findings
The facility failed to protect residents from physical abuse by another resident with dementia, resulting in multiple incidents of abuse over several months. The facility also failed to provide adequate dementia care services to meet residents' needs and prevent aggressive behaviors, despite implementing some interventions and staff education.
Deficiencies (2)
Failure to protect residents from physical abuse by Resident #2 in six separate incidents over a four-month period.
Failure to provide adequate dementia care services to meet residents' needs and prevent aggressive behavioral symptoms.
Report Facts
Abuse incidents: 6
Medication dosage: 0.5
Medication dosage: 1
Activity participation: 9.9
Staff training attendance: 17
Frequency of checks: 15
Frequency of checks: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided care for Resident #2 and discussed abuse incidents and interventions. |
| CNA #1 | Certified Nurse Aide | Provided care for Resident #2 and discussed monitoring and interventions. |
| RN #1 | Registered Nurse | Interviewed regarding Resident #2's condition and medication effects. |
| Nursing Home Administrator | Administrator | Provided facility policies, described staff training and process improvement plans. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted due to complaints of resident-to-resident physical abuse and failure to provide adequate dementia care services.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident abuse by Resident #2 towards Residents #3, #4, #5, and #6. The facility failed to protect residents and implement effective interventions to prevent aggression and ensure safety.
Findings
The facility failed to protect residents from physical abuse by another resident with dementia, resulting in multiple incidents of abuse over several months. The facility also failed to provide adequate dementia care services and implement effective person-centered approaches to prevent aggression and ensure resident safety.
Deficiencies (2)
F0600: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect. The facility failed to ensure four of six sample residents were free from physical abuse by Resident #2 in six separate incidents over four months.
F0744: Provide appropriate treatment and services to residents diagnosed with dementia. The facility failed to provide adequate dementia care services to meet residents' needs and prevent aggression, affecting five of six sample residents.
Report Facts
Abuse incidents: 6
Medication dosage: 1
Activity participation: 9.9
Staff training attendees: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided care for Resident #2 and discussed abuse incidents and interventions. |
| CNA #1 | Certified Nurse Aide | Provided care for Resident #2 and discussed monitoring and interventions. |
| RN #1 | Registered Nurse | Interviewed regarding Resident #2's condition and medication effects. |
| NHA | Nursing Home Administrator | Provided facility policies, described staff training, process improvement plan, and interventions for Resident #2. |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 4
Date: Aug 11, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to provide proper activities of daily living care, fall prevention practices, food safety, and COVID-19 infection control.
Complaint Details
The complaint investigation revealed failures in responding to resident calls for assistance, fall prevention and post-fall care, food safety practices, and COVID-19 testing infection control procedures.
Findings
The facility failed to ensure proper care for residents calling out for assistance, timely and effective fall prevention and post-fall investigations, safe food handling and temperature control, and proper infection control practices during COVID-19 testing.
Deficiencies (4)
F 0676: The facility failed to respond to Resident #231 calling out for assistance, with multiple staff observed ignoring the resident's calls for help.
F 0689: The facility failed to conduct timely post-fall investigations, update care plans, educate staff on fall prevention, and follow care planned interventions, resulting in multiple falls with injuries for Residents #19 and #49.
F 0812: The facility failed to maintain proper cold food temperatures, prevent cross-contamination during meal preparation and delivery, and ensure appropriate glove use when handling ready-to-eat foods in the kitchen.
F 0886: The facility failed to ensure contracted COVID-19 testing staff performed proper hand hygiene and PPE use, including changing gloves between residents and proper doffing procedures.
Report Facts
Residents in sample: 30
Falls experienced by Resident #19: 6
Falls experienced by Resident #49: 8
Staples received by Resident #19: 6
Temperature of cheesecake in walk-in refrigerator: 48
Temperature of cheesecake served unrefrigerated: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Observed ignoring Resident #231 calls for help and interviewed about resident care |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #231 care and fall observations |
| Director of Nursing | Director of Nursing | Interviewed about fall prevention and care plan reviews |
| Dietary Supervisor | Dietary Supervisor | Interviewed about food safety and kitchen observations |
| Contracted Testing Staff #1 | COVID-19 Testing Staff | Observed and interviewed regarding improper PPE and hand hygiene use |
| Contracted Testing Staff #2 | COVID-19 Testing Staff | Observed and interviewed regarding improper PPE and hand hygiene use |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, fall prevention, food safety, and COVID-19 testing practices at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure proper activities of daily living care for a resident, inadequate fall prevention practices leading to multiple falls with injuries, improper food storage and handling resulting in unsafe food temperatures and potential cross-contamination, and improper use of PPE and hand hygiene by contracted COVID-19 testing staff.
Deficiencies (4)
Failure to ensure proper activities of daily living care for Resident #231 who was observed calling out for assistance and not being attended to by staff.
Failure to ensure effective and timely fall prevention practices for Residents #19 and #49, resulting in multiple falls, injuries including lacerations, fractures, and skin tears.
Failure to prepare, distribute, and serve food in a sanitary manner including improper cold food storage and serving temperatures, cross-contamination risks, and improper glove use in the kitchen.
Failure to ensure proper use of infection control practices for COVID-19 testing staff including improper glove use, failure to change gloves between residents, and contamination of PPE supplies.
Report Facts
Residents in sample: 30
Falls experienced by Resident #19: 6
Falls experienced by Resident #49: 8
Temperature of cheesecake in walk-in refrigerator: 48
Temperature of cheesecake left unrefrigerated: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Mentioned in relation to failure to respond to Resident #231 calling out for help | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding Resident #231 care and fall prevention | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding Resident #231 care and fall prevention | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding fall prevention and COVID-19 testing staff training |
| Dietary Supervisor (DS) | Dietary Supervisor | Interviewed regarding food safety and infection control practices in dietary |
| Contracted Testing Staff (CST) #1 | Observed and interviewed regarding improper PPE use during COVID-19 testing | |
| Contracted Testing Staff (CST) #2 | Observed and interviewed regarding improper PPE use during COVID-19 testing | |
| Staff Development Coordinator/Infection Preventionist (SDC/IP) | Infection Preventionist | Interviewed regarding training and oversight of contracted testing staff |
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