Inspection Reports for
Lone Tree Retirement Community, LLC

The inspection included a complaint survey regarding allegations identified as KS00194531.

The facility was found deficient in multiple areas including failure to treat residents with dignity and privacy, failure to provide a written discharge summary, inaccurate resident assessments, unsanitary food storage and preparation practices, improper disposal of garbage, incomplete payroll-based journal staffing data, inadequate infection prevention and control practices including failure to use enhanced barrier precautions and hand hygiene, and lack of a qualified infection preventionist.

The Plan of Correction addresses multiple deficiencies identified during the survey, including resident rights, discharge process, accuracy of assessments, food procurement and sanitation, garbage disposal, payroll based journal accuracy, infection prevention and control, and infection preventionist qualifications. The facility outlines immediate corrective actions, staff education, audits, and monitoring plans to ensure compliance and prevent recurrence.

The facility failed to provide proper respiratory care and cleaning of nebulizer equipment for residents, failed to maintain food safety and sanitization practices in the kitchen, failed to submit complete and accurate staffing information, failed to maintain infection prevention and control including hand hygiene during incontinent care, and failed to maintain a functioning dish machine.

The Plan of Correction addresses multiple deficiencies including nebulizer treatment policies, food storage and safety, staffing information reporting, infection control education, and dishwasher sanitization procedures. Each corrective action includes timelines and responsible parties.

The plan outlines corrective actions related to bed hold policies, oxygen use orders, and equipment cleaning and storage procedures to ensure compliance with regulatory requirements.

The inspection included a complaint investigation identified by KS00156100.

The facility was found deficient in multiple areas including failure to treat a resident with dignity by not providing a privacy bag for an indwelling catheter, failure to provide bed-hold policy notice upon hospital transfer, failure to revise care plans to include oxygen care for residents receiving oxygen, and failure to properly clean, store, and change oxygen and nebulizer tubing for several residents.

The facility identified deficiencies related to fall prevention, including lack of staff adherence to resident care plans and environmental risks. Corrective actions include staff education, updated care plans for residents at high risk of falls, and ongoing assessments to prevent future incidents.

The visit was triggered by multiple complaints (#KS00156602, KS00155347, KS00156388, KS00155716, KS00156617, KS00156616, and KS00156729) regarding falls and supervision failures.

The facility failed to adequately supervise residents and thoroughly investigate falls for residents R6, R7, R8, and R10, resulting in serious injuries including fractures. The investigations and interventions were delayed or inadequate, and staffing shortages contributed to the failures in supervision and timely care.

The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

The facility plans to address medication errors, food safety and storage, narcotics security, and call system maintenance through updated policies, staff education, and monitoring reported at QAPI meetings.

The facility failed to ensure weekly testing of the call light system, performing only monthly checks, which could affect all 35 residents. Additionally, the facility did not provide a policy regarding call light preventative maintenance.

All previously cited deficiencies were corrected as of 05/03/2017, with corrective actions completed and verified during this revisit.

The Plan of Correction outlines multiple corrective actions including staff education on confidentiality, abuse prevention, reporting procedures, investigation protocols, and competency verification for Nurse Aides. It emphasizes immediate suspension of staff suspected of abuse and ongoing monitoring and support for affected residents.

The complaint investigation involved multiple allegations of staff-to-resident abuse including physical abuse and verbal mistreatment by direct care staff G and H, and resident-to-resident altercation involving resident #2 and resident #7. The investigation found credible evidence supporting abuse allegations leading to termination of staff. The facility failed to immediately report and investigate some allegations and failed to protect residents during investigations, placing all residents in immediate jeopardy.

The facility failed to protect residents from abuse by staff, failed to immediately report and investigate abuse allegations, failed to provide social services after abuse incidents, failed to revise care plans after resident-to-resident altercations, and failed to verify nurse aide registry prior to employment. Several staff were terminated following substantiated abuse incidents. Immediate jeopardy was identified and abated with staff education and suspensions.

The survey found the most serious deficiencies at the facility to be F223, K", CFR 483.12(a)(1), F225, "L", CFR 483.12(a)(3)(4)(c)(1)-(4), which was determined to be immediate jeopardy, resulting in enforcement remedies including a civil monetary penalty and potential denial of payment and termination if substantial compliance is not achieved.

The revisit confirmed that the deficiencies previously cited under regulations 483.24 and 483.25(d)(1)(2)(n)(1)-(3) were corrected as of the revisit date.

The survey found the most serious deficiency to be F523, an 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective February 11, 2017.

The complaint investigation (KS0010330) found substantiated deficiencies related to failure in nursing assessment after elopement and inadequate supervision to prevent accidents due to malfunctioning or disabled door alarms and unsecured exit doors.

The facility failed to provide a thorough nursing assessment following an elopement of a cognitively impaired resident in cold weather, and failed to provide adequate supervision and functional door alarms to prevent accidents for 8 cognitively impaired and independently mobile residents. Multiple door alarms were malfunctioning or disabled without proper checks, and an unalarmed door led to an enclosed courtyard accessible to residents.

The report shows that previously identified deficiencies under regulations 483.25(c) and 483.60(a),(b) were corrected as of the revisit date.

The plan addresses deficiencies related to skin assessments and pharmaceutical services, including procedures to prevent skin issues and ensure accurate medication administration and documentation.

The facility failed to provide necessary services to prevent one resident from developing a stage 2 pressure ulcer and failed to ensure medications were administered as ordered to another resident.

The survey found isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The survey found the most serious deficiency to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payment for new admissions and termination of provider agreement were outlined if substantial compliance was not achieved.

The revisit confirmed that all previously identified deficiencies were corrected by 08/29/2014 as indicated by the correction completion dates for each cited regulation.

The survey found the most serious deficiency to be a 'G' level deficiency, isolated, with no actual harm but potential for more than minimal harm that is not immediate jeopardy. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were outlined.

The plan addresses multiple deficiencies including maintenance of call lights, housekeeping sanitation, timely completion of admission assessments, accuracy of MDS entries, comprehensive care planning, skin care and pressure ulcer prevention, fall prevention, medication management including black box warnings, dietary staffing and food service quality.

The facility had multiple deficiencies including failure to maintain call lights accessible, inadequate housekeeping and maintenance, incomplete comprehensive assessments, inaccurate assessments, incomplete care plans, failure to monitor skin conditions, inadequate fall prevention and supervision, insufficient dietary staffing, poor food quality, unsanitary food handling, and failure to monitor drug regimen irregularities.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

The plan addresses deficiencies related to food preparation and nutrition, food procurement and sanitation, garbage disposal, and infection control. The facility outlines corrective actions including staff retraining, policy revisions, ongoing monitoring, and infection control program implementation.

The visit was triggered by a complaint investigation (#KS00064959) concerning food preparation, sanitary conditions, garbage disposal, and infection control practices. The complaint was substantiated with multiple deficiencies found.

The facility failed to provide full portions of pureed meat to residents, failed to serve and store food under sanitary conditions, improperly disposed of garbage, and did not follow infection control protocols including improper cleaning and transport of linens. These deficiencies affected multiple residents and posed risks for infection and nutritional inadequacies.

This Plan of Correction is related to a complaint investigation at Meade District Hosp LTCU dated 01/12/2017.

The plan addresses deficiencies related to quality of life and safety, including ensuring complete nursing assessments following resident elopements and maintaining a safe environment free from accident hazards with adequate supervision and device use.