Inspection Reports for
Mountain View Post Acute
835 TENDERFOOT HILL RD, COLORADO SPRINGS, CO, 80906-
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
30.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
488% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
120
90
60
30
0
Occupancy
Latest occupancy rate
78% occupied
Based on a September 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 11, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident safety, abuse prevention, infection control, and maintaining a homelike environment.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, protecting residents from physical abuse, and implementing an effective infection prevention and control program. Specific issues included broken towel racks, unclean resident rooms, physical altercations between residents, and housekeeping staff failing to follow proper cleaning and hand hygiene procedures.
Deficiencies (3)
Failed to maintain a comfortable and homelike environment including broken towel racks, broken window seals, unclean rooms, and broken shower room lights.
Failed to protect residents from physical abuse, specifically a substantiated physical altercation between two residents resulting in a skin tear.
Failed to provide and implement an infection prevention and control program, including improper cleaning procedures and failure to perform hand hygiene and glove changes appropriately.
Report Facts
Towel racks ordered: 45
Residents in sample: 53
Residents involved in abuse incident: 2
Duration of safety checks: 72
Observation duration: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Interviewed regarding responsibility for ensuring residents' rooms were clean and stocked with towels. |
| Maintenance Director | Maintenance Director | Interviewed about broken towel racks and maintenance audits. |
| ADON | Assistant Director of Nursing | Interviewed about nursing staff responsibilities and post-incident measures. |
| CNA #9 | Certified Nurse Aide | Witnessed physical altercation between residents #111 and #66. |
| CNA #2 | Certified Nurse Aide | Interviewed about resident behaviors and staff monitoring. |
| CNA #1 | Certified Nurse Aide | Interviewed about resident behaviors and staff supervision. |
| LPN #5 | Licensed Practical Nurse | Interviewed about resident behaviors and monitoring. |
| RN #3 | Registered Nurse | Interviewed about assessment after resident altercation. |
| NHA | Nursing Home Administrator | Provided facility policies and concluded substantiation of abuse incident. |
| HK #1 | Housekeeper | Observed failing to perform hand hygiene and proper cleaning procedures. |
| HK #2 | Housekeeper | Observed failing to perform hand hygiene and proper cleaning procedures. |
| Infection Preventionist | Infection Preventionist | Interviewed about proper hand hygiene and cleaning protocols. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 11, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident environment, abuse prevention, and infection control at Mountain View Post Acute nursing home.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, protecting residents from physical abuse, and implementing an effective infection prevention and control program. Multiple environmental issues, a substantiated resident-to-resident physical abuse incident, and inadequate housekeeping practices were documented.
Deficiencies (3)
F 0584: The facility failed to maintain a comfortable and homelike environment by not providing clean washcloths, timely fixing broken towel racks and window seals, ensuring cleanliness of resident rooms, and repairing lighting in the shower room.
F 0600: The facility failed to protect two residents from physical abuse by each other, resulting in a substantiated incident with a skin tear injury to one resident.
F 0880: The facility failed to maintain an infection control program by not ensuring housekeeping staff followed proper cleaning procedures, including hand hygiene, glove changes, and disinfection of high-touch surfaces.
Report Facts
Residents in sample: 53
Residents involved in abuse incident: 2
Towel racks ordered: 45
Duration of observation: 40
72-hour charting checks: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Certified Nurse Aide | Witnessed and intervened in resident-to-resident physical abuse incident |
| MTD | Maintenance Director | Reported on towel rack audit and maintenance issues |
| ADON | Assistant Director of Nursing | Interviewed regarding towel provision and abuse incident management |
| HK #1 | Housekeeper | Observed failing to follow proper cleaning and hand hygiene procedures |
| HK #2 | Housekeeper | Observed failing to follow proper cleaning and hand hygiene procedures |
| RN #3 | Registered Nurse | Assessed residents after abuse incident |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and call light system functionality at Mountain View Post Acute nursing home.
Findings
The facility failed to ensure timely administration of medications to Resident #6, with multiple late doses documented, and failed to maintain a fully functional call light system, resulting in delayed staff response to resident calls for assistance.
Deficiencies (2)
Failure to ensure Resident #6 received medications in a timely manner as prescribed, with multiple late medication administrations documented.
Failure to ensure the call light system was functioning properly, resulting in staff being unable to hear call light alerts away from the centralized staff work area and delayed response times.
Report Facts
Late medication administrations: 102
Late Baclofen administrations: 16
Late Eliquis administrations: 9
Late Gabapentin administrations: 9
Medication doses late on 4/7/25: 12
Call light response time range: 102
Call light response time range: 25
Resident grievances: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration audit as responsible for 87 late medication events |
| Staff Development Coordinator | SDC | Interviewed regarding medication cart assignments and medication administration challenges |
| Unit Manager | UM | Interviewed about medication administration timing and cart assignments |
| Assistant Director of Nursing | ADON | Interviewed about medication ordering changes and administration windows |
| Director of Nursing | DON | Interviewed about medication administration schedule and audit results |
| Nursing Home Administrator | NHA | Interviewed about call light system issues and response expectations |
| Certified Nurse Aide #3 | CNA | Interviewed about call light system audibility and visibility issues |
| Licensed Practical Nurse #1 | LPN | Interviewed about call light system limitations and visibility |
| Certified Nurse Aide #1 | CNA | Interviewed about call light system audibility and visibility challenges |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, medication administration, and call light system functionality at Mountain View Post Acute nursing home.
Findings
The facility failed to ensure timely administration of medications to Resident #6, with multiple late medication events documented. Additionally, the call light system was found to be inadequate, with alarms not audible in hallways and obstructed visibility, resulting in delayed staff response to resident calls for assistance.
Deficiencies (2)
F0658: The facility failed to ensure Resident #6 received medications in a timely manner as prescribed, with multiple late administrations documented between 4/1/25 and 4/15/25, including Baclofen, Eliquis, and Gabapentin.
F0919: The facility failed to ensure the call light system was fully functional, with alarms only audible at the nurse's station and not in hallways, obstructed visibility of call lights, and delayed staff response to resident calls.
Report Facts
Late medication administrations: 102
Late Baclofen administrations: 16
Late Eliquis administrations: 9
Late Gabapentin administrations: 9
Medication doses late on 4/7/25: 12
Call light response time range: 102
Call light response time range: 25
Resident grievances: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and services to a resident diagnosed with a mental disorder or psychosocial adjustment difficulty.
Complaint Details
The complaint investigation focused on Resident #2's care related to mental health and psychosocial needs. The facility was found deficient in providing adequate psychosocial support, behavioral health referrals, and proper monitoring of psychoactive medications. The resident exhibited escalating behaviors, including delusions, paranoia, aggression, and attempts to leave the facility, which were not adequately managed or documented.
Findings
The facility failed to ensure that Resident #2, diagnosed with multiple mental health conditions and a history of trauma, received appropriate individualized care, psychosocial support, and monitoring. Despite escalating behaviors and traumatic history, the resident was not reviewed in psychoactive drug meetings nor referred for behavioral health counseling, and interventions were inconsistently documented.
Deficiencies (1)
Failure to provide appropriate treatment and services to a resident with mental disorder or psychosocial adjustment difficulty.
Report Facts
Residents Affected: 3
Medication doses missed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Interviewed regarding Resident #2's behaviors and interventions. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #2's agitation and staff interventions. |
| SSD | Social Services Director | Interviewed about psychoactive drug meetings and behavioral health referrals. |
| SSDMC | Social Services Director for Memory Care Unit | Interviewed about Resident #2's behaviors and interventions. |
| NHA | Nursing Home Administrator | Interviewed about facility placement decisions and behavioral health support. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 26, 2025
Visit Reason
The inspection was conducted to investigate the facility's failure to provide appropriate treatment and services to a resident diagnosed with a mental disorder or psychosocial adjustment difficulty, specifically Resident #2, to meet his emotional and psychosocial needs.
Complaint Details
The investigation was complaint-related, focusing on Resident #2's care. The complaint was substantiated as the facility failed to provide adequate psychosocial and behavioral health support, did not document behaviors or interventions properly, and did not include the resident in psychoactive drug meetings or psychiatric evaluations.
Findings
The facility failed to ensure Resident #2 received individualized care and ongoing assessment to address his mental and psychosocial wellbeing. Despite documented behaviors including delusions, paranoia, aggression, and escalating agitation, the facility did not provide adequate psychosocial support, behavioral health counseling, or psychiatric review. The resident was eventually discharged to another facility with a secure memory care unit.
Deficiencies (1)
F 0742: The facility failed to provide appropriate treatment and services to a resident with mental disorder or psychosocial adjustment difficulty to attain and maintain the highest practicable mental and psychosocial wellbeing. Resident #2's behaviors and needs were not adequately addressed with individualized care or ongoing assessment.
Report Facts
Residents affected: 3
Missed antidepressant doses: 9
Inspection Report
Routine
Deficiencies: 5
Date: Sep 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and pharmaceutical services at Mountain View Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide timely incontinence care to Resident #11, failure to follow physician orders for skin and wound care for Residents #2 and #12, failure to administer medication as ordered for Resident #7, failure to maintain proper controlled substance records, and failure to follow infection control procedures for residents on enhanced barrier precautions.
Deficiencies (5)
Failure to provide timely incontinence care for Resident #11.
Failure to ensure physician's orders for skin and wound care were followed for Residents #2 and #12.
Failure to ensure Resident #7 received medication as ordered by the physician.
Failure to maintain a system of controlled substance records for discontinued controlled substances.
Failure to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP).
Report Facts
Residents reviewed: 25
Residents affected: 3
Residents affected: 1
Residents affected: 1
Medication doses missed: 5
Date of survey completion: Sep 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Aide | Named in incontinence care deficiency for Resident #11 and infection control deficiency for Resident #25 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding incontinence care and medication administration issues |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration and infection control |
| RN #1 | Registered Nurse | Interviewed regarding incontinence care and medication administration |
| RN #2 | Registered Nurse | Interviewed regarding medication administration and infection control |
| RN #3 | Registered Nurse | Interviewed regarding wound care documentation |
| CNA #1 | Certified Nursing Aide | Interviewed regarding infection control practices |
| CNA #3 | Certified Nursing Aide | Interviewed regarding infection control practices |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incontinence care, medication administration, and controlled substance management |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding controlled substance management |
| Regional Director of Clinical Services | Regional Director of Clinical Services (RDCS) | Interviewed regarding wound care documentation |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control program and staff compliance |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 5, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, treatment, infection control, medication management, and controlled substance handling.
Findings
The facility was found deficient in providing timely incontinence care, following physician orders for wound care and medication administration, maintaining accurate controlled substance records, and ensuring proper infection control procedures for residents on enhanced barrier precautions.
Deficiencies (4)
F 0677: The facility failed to provide timely incontinence care for Resident #11, who waited up to two hours and 45 minutes for assistance with a brief change.
F 0684: The facility failed to ensure physician's orders for skin and wound care were followed for Residents #2 and #12, and Resident #7 did not receive medication as ordered.
F 0755: The facility failed to maintain a system of controlled substance records for discontinued controlled substances, resulting in a large inventory of medications awaiting destruction without proper reconciliation.
F 0880: The facility failed to ensure nursing staff followed proper infection control procedures for Resident #25 on enhanced barrier precautions, including failure to perform hand hygiene and don required PPE.
Report Facts
Sample residents reviewed: 25
Residents affected by incontinence care deficiency: 1
Residents affected by wound care and medication deficiency: 3
Residents affected by controlled substance record deficiency: Some
Residents affected by infection control deficiency: Few
Wait time for incontinence care: 165
Medication administration missed doses: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Aide | Named in incontinence care delay and infection control PPE failure |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding incontinence care and medication administration issues |
| RN #1 | Registered Nurse | Interviewed regarding incontinence care and medication administration issues |
| DON | Director of Nursing | Interviewed regarding incontinence care, medication ordering, and controlled substance handling |
| NHA | Nursing Home Administrator | Interviewed regarding controlled substance handling and facility policies |
| RN #3 | Registered Nurse | Interviewed regarding wound care documentation and medication administration records |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration and infection control procedures |
| RN #2 | Registered Nurse | Interviewed regarding infection control procedures and medication administration |
| CNA #1 | Certified Nursing Aide | Interviewed regarding infection control PPE use |
| CNA #3 | Certified Nursing Aide | Interviewed regarding infection control PPE use |
| IP | Infection Preventionist | Interviewed regarding infection control audits and staff training |
Inspection Report
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care following concerns about the monitoring of Resident #1 after a suspected illicit drug use and change of condition.
Findings
The facility failed to adequately monitor Resident #1 who had elevated blood pressure and pulse following suspected illicit drug use. Despite orders for assessments and monitoring over 72 hours, there was no documented follow-up or vital signs after 2/2/24, and the resident refused some assessments without proper documentation. Staff interviews confirmed lapses in monitoring and documentation.
Deficiencies (1)
Failure to monitor Resident #1 with a change of condition after suspected illicit drug use according to professional standards.
Report Facts
Elevated blood pressure readings: 176
Elevated pulse readings: 131
Baseline pulse range: 72
Baseline blood pressure range: 98
Monitoring period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #1 | Licensed Practical Nurse | Interviewed regarding monitoring requirements and difficulties with EMR system |
| Interim director of nursing | Interim Director of Nursing | Interviewed about failure to monitor Resident #1 and lack of documentation |
| Registered nurse #1 | Registered Nurse | Interviewed about vital sign monitoring frequency and assessment requirements |
Inspection Report
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care following concerns about the monitoring of a resident with a change of condition after suspected illicit drug use.
Findings
The facility failed to adequately monitor Resident #1 after a change of condition related to suspected illicit drug use. There was a lack of ongoing assessment and documentation of vital signs and symptoms for at least 72 hours as required by facility policy and professional standards.
Deficiencies (1)
F 0658: The facility failed to monitor Resident #1 with elevated blood pressure and pulse following suspected illicit drug use. There was no documentation of ongoing assessments or vital signs for at least 72 hours as required by policy.
Report Facts
Elevated blood pressure readings: 176
Elevated pulse readings: 131
72 hours: 72
Inspection Report
Routine
Deficiencies: 21
Date: Nov 16, 2023
Visit Reason
Routine state inspection of Mountain View Post Acute facility to assess compliance with healthcare regulations including resident rights, care quality, environment, infection control, and safety.
Findings
The facility was found deficient in multiple areas including resident dignity and timely response to call lights, environmental maintenance, abuse prevention and investigation, MDS data submission, activities programming, pressure ulcer care, fall prevention, nutrition and food service, respiratory care, dialysis care, infection control including COVID-19 protocols and Legionella water management, and vaccine administration.
Deficiencies (21)
F 0550: Facility failed to ensure residents were treated with dignity and timely response to call lights, resulting in residents waiting up to 111 minutes for assistance.
F 0558: Facility failed to reasonably accommodate resident preferences including treatment of edema, comfort, and care plan updates for Resident #38.
F 0584: Facility failed to maintain sanitary, orderly, and comfortable environment in 22 of 105 resident rooms with damaged walls, peeling sheetrock, exposed pipes, and dirty heater vents.
F 0600: Facility failed to protect residents from abuse, neglect, and exploitation in seven of nine incidents involving 11 residents, including inadequate supervision and incomplete care plan updates for aggressive residents.
F 0610: Facility failed to complete and transmit encoded Minimum Data Set (MDS) discharge assessment for Resident #58 upon discharge to community.
F 0679: Facility failed to provide individualized meaningful activities for residents with dementia, including Residents #90, #83, #42, and #79, and lacked dementia training for staff.
F 0686: Facility failed to provide appropriate pressure ulcer care and prevention for Residents #93 and #62, resulting in progression to stage 4 pressure ulcer and worsening wounds.
F 0689: Facility failed to implement fall prevention interventions for Resident #186, who was observed in bed with the bed in a high position contrary to care plan.
F 0692: Facility failed to follow physician orders and timely address nutritional needs for Residents #75, #79, and #111, resulting in significant unplanned weight loss and inconsistent provision of supplements.
F 0695: Facility failed to administer oxygen therapy at the ordered liter flow for Residents #185 and #2, and failed to document resident refusals.
F 0698: Facility failed to ensure dialysis care for Resident #66 including lack of physician orders for dialysis treatment and shunt assessment, incomplete care plan, and poor communication with dialysis provider.
F 0744: Facility failed to provide person-centered dementia care and activities for Residents #90, #83, #42, #79, and #85, with no scheduled activities during survey and lack of dementia training documentation for staff.
F 0804: Facility failed to ensure food was palatable in taste, temperature, texture and appearance, and failed to address resident food complaints.
F 0806: Facility failed to provide food that accommodated resident allergies, intolerances, and preferences for Residents #87, #84, and #53.
F 0809: Facility failed to serve meals at regular times and residents reported long wait times and cold food.
F 0812: Facility failed to ensure food safety including reheating modified consistency foods to safe temperatures, use of clean cutting boards, proper hand hygiene during food preparation, and maintaining clean kitchen and food service areas.
F 0849: Facility failed to ensure hospice services met professional standards including lack of written plan of care, lack of orientation for hospice staff, and poor communication between hospice and facility staff for Resident #185.
F 0880: Facility failed to implement an effective Legionella water management program, with water temperatures in the range that promote Legionella growth and lack of follow-up monitoring.
F 0880 (continued): Facility failed to ensure proper infection control practices during COVID-19 outbreak including improper PPE use, lack of resident isolation enforcement, inadequate disinfection of shared equipment, and improper hand hygiene.
F 0880 (continued): Facility failed to ensure proper cleaning and disinfection of shared glucometers between resident use.
F 0921: Facility failed to provide a safe, functional, and comfortable environment by not installing backflow prevention devices on hand held shower hoses in resident rooms and common shower room.
Report Facts
Resident wait time for call light response: 111
Resident wait time for call light response: 47
Resident wait time for call light response: 120
Resident wait time for call light response: 120
Resident weight loss percent: 12
Resident weight loss percent: 5.56
Resident weight loss percent: 7.88
Resident weight loss percent: 16.55
Water temperature range: 106
Water temperature range: 109
Water temperature range: 110
Water temperature range: 112
Water temperature range: 163
Meal delivery delay: 150
COVID-19 positive residents: 26
COVID-19 positive staff: 18
Resident weight: 100
Resident weight: 92
Resident weight: 88
Resident weight: 108
Resident weight: 102
Resident weight: 165
Resident weight: 152
Resident weight: 142.7
Resident weight: 142.4
Resident weight: 137.7
Resident weight: 136.8
Resident weight: 131.4
Resident weight: 130.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in call light response delays and food delivery complaints |
| CNA #2 | Certified Nurse Aide | Named in call light response delays and resident care |
| CNA #3 | Certified Nurse Aide | Named in abuse prevention and resident care |
| CNA #4 | Certified Nurse Aide | Named in hospice care knowledge |
| CNA #6 | Certified Nurse Aide | Named in infection control and meal tray handling |
| CNA #7 | Certified Nurse Aide | Named in nutrition and activities programming |
| CNA #9 | Certified Nurse Aide | Named in resident interaction and activities |
| CNA #10 | Certified Nurse Aide | Named in resident interaction and activities |
| LPN #1 | Licensed Practical Nurse | Named in infection control and nutrition |
| LPN #2 | Licensed Practical Nurse | Named in call light response delays and resident care |
| LPN #3 | Licensed Practical Nurse | Named in infection control and nutrition |
| LPN #4 | Licensed Practical Nurse | Named in wound care and nutrition |
| LPN #5 | Licensed Practical Nurse | Named in activities programming and nutrition |
| LPN #6 | Licensed Practical Nurse | Named in wound care and resident care |
| RN #2 | Registered Nurse | Named in oxygen therapy and resident care |
| RN #5 | Registered Nurse | Named in glucometer use and resident care |
| RN #7 | Registered Nurse | Named in glucometer use and resident care |
| DM | Dietary Manager | Named in food service and kitchen observations |
| MTD | Maintenance Director | Named in water management and facility maintenance |
| DON | Director of Nursing | Named in multiple care and compliance issues |
| NHA | Nursing Home Administrator | Named in multiple care and compliance issues |
| CNC | Corporate Nurse Consultant | Named in multiple care and compliance issues |
| RD | Registered Dietitian | Named in nutrition care and assessments |
| HN | Hospice Nurse | Named in hospice care and communication |
Inspection Report
Routine
Deficiencies: 20
Date: Nov 16, 2023
Visit Reason
Routine state survey inspection of Mountain View Post Acute nursing home to assess compliance with federal and state regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and timely response to call lights, resident rights and preferences, environmental maintenance, abuse prevention and investigation, MDS assessment and transmission, activities programming, pressure ulcer care, fall prevention, nutrition and hydration, respiratory care, dialysis services, food service quality and safety, infection control including COVID-19 protocols, and water management for Legionella prevention.
Deficiencies (20)
Failure to ensure residents were treated with dignity and timely response to call lights, resulting in residents waiting up to 111 minutes for assistance.
Failure to accommodate resident preferences and needs for edema treatment and comfort, including lack of timely care plan updates and environmental adjustments.
Failure to maintain sanitary, orderly, and comfortable environment in 22 of 105 resident rooms, including damaged walls, peeling sheetrock, exposed pipes, and dirty heater vents.
Failure to prevent resident-to-resident abuse involving multiple residents, inadequate supervision and care planning for aggressive residents, and failure to update care plans after incidents.
Failure to investigate an allegation of resident-to-resident physical abuse between Residents #29 and #99.
Failure to complete and transmit required Minimum Data Set (MDS) discharge assessment for Resident #58 upon discharge to the community.
Failure to provide individualized meaningful activities and consistent activity programming for residents with dementia on the memory support unit.
Failure to provide appropriate pressure ulcer care and prevention, resulting in progression to stage 4 pressure ulcer with infection requiring hospitalization for Resident #93, and worsening pressure wounds for Resident #62.
Failure to implement fall prevention interventions for Resident #186, resulting in resident found in bed with legs hanging off and bed in high position.
Failure to follow physician orders and timely address significant weight loss and nutritional needs for Residents #75, #79, and #111, including inconsistent provision of supplements and lack of swallowing assessments.
Failure to administer oxygen therapy at the ordered flow rate for Residents #185 and #2, and failure to document refusals or noncompliance.
Failure to ensure dialysis services were provided consistent with physician orders, including lack of communication with dialysis center, lack of physician orders for dialysis care, and failure to assess dialysis access site.
Failure to provide person-centered care and meaningful activities for residents with dementia, including lack of scheduled activities and lack of staff training on dementia care.
Failure to ensure food was palatable, served at appropriate temperature, and resident food preferences and allergies were accommodated, including frequent food complaints and lack of alternatives.
Failure to serve meals at regular times and prevent prolonged wait times for residents, with meal deliveries observed up to two and a half hours late.
Failure to maintain kitchen and food service areas in sanitary condition, including use of heavily scored and stained cutting boards, improper hand hygiene by dietary staff, and dirty kitchen surfaces and equipment.
Failure to ensure hospice services were coordinated with facility staff, including lack of written hospice care plan in resident record and lack of orientation for hospice staff.
Failure to implement effective infection prevention and control measures during COVID-19 outbreak, including improper use of PPE by staff, lack of resident mask use and isolation compliance, and inadequate disinfection of shared equipment.
Failure to offer and provide pneumococcal vaccination to Resident #43 despite documented eligibility and consent.
Failure to install backflow prevention devices on hand held shower hoses in resident rooms and shower room, increasing risk of water contamination.
Report Facts
Weight loss: 12
Weight loss: 5.56
Weight loss: 16.55
Temperature: 119
Temperature: 118
Temperature: 121
Temperature: 117
Water temperature: 106
Water temperature: 109
Water temperature: 110
Water temperature: 112
Water temperature: 123
Water temperature: 158
Water temperature: 160
Weight: 100
Weight: 92
Weight: 88
Weight: 108
Weight: 102
Weight: 165
Weight: 152
Weight: 142.7
Weight: 142.4
Weight: 137.7
Weight: 136.8
Weight: 130.1
Weight: 131.4
COVID-19 positive residents: 25
COVID-19 symptomatic residents: 26
COVID-19 positive staff: 18
New COVID-19 positive residents: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings for failure to respond timely to call lights and failure to provide drinks to resident #87 |
| CNA #3 | Certified Nurse Aide | Named in findings for failure to respond timely to call lights and failure to provide drinks to resident #87 |
| LPN #2 | Licensed Practical Nurse | Named in findings for failure to respond timely to call lights and failure to provide orientation |
| LPN #4 | Licensed Practical Nurse | Named in findings for failure to respond timely to call lights and failure to provide orientation |
| DON | Director of Nursing | Named in findings for failure to ensure timely response to call lights, failure to update care plans after abuse incidents, failure to ensure hospice coordination, failure to ensure oxygen therapy compliance, failure to ensure dialysis care coordination, failure to ensure nutrition interventions, failure to ensure infection control compliance |
| NHA | Nursing Home Administrator | Named in findings for failure to ensure timely response to call lights, failure to ensure hospice coordination, failure to ensure nutrition interventions, failure to ensure infection control compliance |
| CNA #7 | Certified Nurse Aide | Named in findings for failure to provide nutrition supplements to residents #75 and #79 |
| DM | Dietary Manager | Named in findings for failure to ensure food quality, failure to ensure timely meal delivery, failure to ensure kitchen sanitation, failure to ensure resident food preferences accommodated |
| WD | Wound Care Nurse | Named in findings for failure to ensure pressure ulcer care coordination and monitoring |
| CNC | Corporate Nurse Consultant | Named in findings for failure to ensure abuse investigations, failure to ensure nutrition monitoring, failure to ensure dialysis care coordination, failure to ensure infection control compliance |
| MTD | Maintenance Director | Named in findings for failure to ensure water temperature monitoring and Legionella prevention, failure to ensure backflow prevention devices installed |
| RN #2 | Registered Nurse | Named in findings for failure to ensure oxygen therapy compliance |
| RN #7 | Registered Nurse | Named in findings for failure to ensure glucometer disinfection |
| LPN #1 | Licensed Practical Nurse | Named in findings for failure to ensure glucometer disinfection |
| LPN #3 | Licensed Practical Nurse | Named in findings for failure to ensure glucometer disinfection |
Inspection Report
Routine
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
Routine inspection to assess compliance with regulatory standards including resident care, medication administration, meal services, staffing, and infection control.
Findings
The facility was found deficient in multiple areas including timely meal service, medication administration, assistance with activities of daily living, pressure injury prevention, ostomy care, staffing levels, food quality, hydration, and vaccination policies. Residents and staff interviews, observations, and record reviews revealed delays, inadequate care, and poor communication impacting resident well-being.
Deficiencies (9)
F0550: The facility failed to ensure timely meal service, resulting in residents receiving late and cold meals with inadequate communication between kitchen and dining staff.
F0658: The facility failed to administer scheduled medications timely for multiple residents, with no evidence of provider notification for late doses.
F0677: The facility failed to provide scheduled showers and baths or alternatives for dependent residents, with documentation showing residents received fewer showers than planned.
F0686: The facility failed to implement pressure injury prevention interventions including timely repositioning and use of pressure relieving devices for a resident at risk.
F0691: The facility failed to provide routine monitoring and proper care of a resident's colostomy, resulting in leakage and strong odors without appropriate assessment or education.
F0725: The facility failed to provide sufficient nursing staff to meet resident care needs, resulting in delayed care, unanswered call lights, and inadequate assistance with activities.
F0804: The facility failed to ensure food was palatable, properly prepared, and available in sufficient quantities, with residents reporting cold, bland, and limited food choices.
F0807: The facility failed to provide adequate hydration, with residents lacking access to water and hydration carts not in use, resulting in residents having to request fluids.
F0883: The facility failed to develop and implement policies and procedures for pneumococcal vaccinations, including failure to educate a resident who refused the vaccine and failure to document offers or refusals.
Report Facts
Resident census: 124
Residents dependent on staff for bathing: 7
Residents needing assistance of one or two staff to bathe: 67
Residents dependent on staff for dressing: 1
Residents needing assistance of one or two staff to dress: 105
Residents dependent on staff to transfer: 15
Residents needing assistance of one or two staff to transfer: 58
Residents dependent on staff for toilet use: 30
Residents needing assistance of one or two staff to toilet: 69
Residents dependent on staff to eat: 3
Residents needing assistance of one or two staff to eat: 46
Residents frequently incontinent of bladder: 101
Residents frequently incontinent of bowel: 66
Residents in wheelchairs all or most of the time: 64
Residents with diagnosis of dementia: 44
Residents with current pressure injuries: 3
Residents receiving preventive skin care: 118
Residents receiving hospice services: 7
Residents receiving respiratory care: 45
Residents with contractures: 32
Residents on pain management program: 81
Inspection Report
Routine
Census: 124
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, meal services, staffing, hygiene assistance, pressure ulcer prevention, ostomy care, vaccinations, and hydration in the nursing facility.
Findings
The facility was found deficient in multiple areas including timely meal service, medication administration, assistance with activities of daily living, pressure ulcer prevention, ostomy care, staffing adequacy, food quality and palatability, hydration provision, and vaccination policies. Residents and staff interviews, observations, and record reviews revealed delays, inadequate care, poor communication, and failure to follow care plans and policies.
Deficiencies (9)
Failure to ensure timely meal service and maintain residents' dignity during dining.
Failure to administer scheduled medications in a timely manner for multiple residents.
Failure to provide scheduled showers and baths or alternatives for residents unable to carry out ADLs independently.
Failure to implement interventions to prevent pressure injuries for a resident at risk.
Failure to provide necessary ostomy care consistent with professional standards and resident preferences, including monitoring for leakage and proper appliance fit.
Failure to provide sufficient nursing staff to meet residents' care needs, resulting in delayed and inadequate care.
Failure to ensure food was palatable, served at safe temperatures, and resident food complaints were addressed.
Failure to ensure residents consistently received drinks sufficient to maintain hydration and consistent with care plans and preferences.
Failure to develop and implement policies and procedures related to pneumococcal immunizations, including education on refusal and documentation.
Report Facts
Resident census: 124
Residents dependent on staff for bathing: 7
Residents needing assistance of one or two staff to bathe: 67
Residents dependent on staff for dressing: 1
Residents needing assistance of one or two staff to dress: 105
Residents dependent on staff for transfer: 15
Residents needing assistance of one or two staff to transfer: 58
Residents dependent on staff for toilet use: 30
Residents needing assistance of one or two staff to toilet: 69
Residents dependent on staff to eat: 3
Residents needing assistance of one or two staff to eat: 46
Residents frequently incontinent of bladder: 101
Residents frequently incontinent of bowel: 66
Residents in wheelchairs all or most of the time: 64
Residents with diagnosis of dementia: 44
Residents with current pressure injuries: 3
Residents receiving preventive skin care: 118
Residents receiving hospice services: 7
Residents receiving respiratory care: 45
Residents with contractures: 32
Residents on pain management program: 81
Inspection Report
Routine
Census: 124
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, meal services, staffing, hygiene assistance, pressure ulcer prevention, ostomy care, hydration, and vaccination policies.
Findings
The facility was found deficient in multiple areas including timely meal service, medication administration, assistance with activities of daily living, pressure ulcer prevention, ostomy care, adequate staffing, food quality and palatability, hydration, and vaccination procedures. Residents and staff interviews, observations, and record reviews revealed systemic issues such as delayed meals and medications, insufficient staff, inadequate hygiene care, poor food quality, lack of hydration support, and incomplete vaccination education and documentation.
Deficiencies (9)
Failed to ensure timely meal service and maintain residents' dignity during meal times.
Failed to ensure scheduled medications were given in a timely manner to multiple residents.
Failed to provide scheduled showers and baths or alternatives for dependent residents.
Failed to implement interventions to prevent pressure injuries for a resident at risk.
Failed to provide necessary ostomy care consistent with professional standards and resident preferences.
Failed to provide sufficient nursing staff to meet residents' care needs, resulting in delayed and inadequate care.
Failed to ensure food was palatable, served at safe temperatures, and resident food complaints were addressed.
Failed to ensure residents consistently received fluids according to care plans and preferences, and hydration carts were not available.
Failed to develop and implement policies and procedures for pneumococcal vaccinations, including education on refusal and documentation.
Report Facts
Resident census: 124
Residents dependent on staff for bathing: 7
Residents needing assistance of one or two staff to bathe: 67
Residents dependent on staff for dressing: 1
Residents needing assistance of one or two staff to dress: 105
Residents dependent on staff to transfer: 15
Residents needing assistance of one or two staff to transfer: 58
Residents dependent on staff for toilet use: 30
Residents needing assistance of one or two staff to toilet: 69
Residents dependent on staff to eat: 3
Residents needing assistance of one or two staff to eat: 46
Residents frequently incontinent of bladder: 101
Residents frequently incontinent of bowel: 66
Residents in wheelchairs all or most of the time: 64
Residents with diagnosis of dementia: 44
Residents with current pressure injuries: 3
Residents receiving preventive skin care: 118
Residents receiving hospice services: 7
Residents receiving respiratory care: 45
Residents with contractures: 32
Residents on pain management program: 81
Inspection Report
Routine
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility standards including resident care, medication administration, meal services, staffing, and infection control.
Findings
The facility was found deficient in multiple areas including timely meal service, medication administration, assistance with activities of daily living, pressure injury prevention, ostomy care, staffing adequacy, food quality, hydration, and vaccination policies. Residents and staff interviews, observations, and record reviews documented delays, inadequate care, poor food quality, insufficient fluids, and lack of proper documentation and education.
Deficiencies (9)
F0550: The facility failed to ensure meals were served timely and residents' dignity was maintained during meal service.
F0658: The facility failed to ensure scheduled medications were administered timely to multiple residents, with no provider notification for late doses.
F0677: The facility failed to provide scheduled showers and baths or alternatives for residents unable to carry out activities of daily living independently.
F0686: The facility failed to implement interventions to prevent pressure injuries for a resident at risk, including repositioning and use of pressure relieving devices.
F0691: The facility failed to provide routine monitoring and proper care of a resident's colostomy, resulting in leakage and strong odors.
F0725: The facility failed to provide sufficient nursing staff to meet residents' care needs, resulting in delayed care, unanswered call lights, and inadequate assistance.
F0804: The facility failed to ensure food was palatable, served at safe temperatures, and resident food preferences were honored.
F0807: The facility failed to consistently offer, encourage, and provide fluids to residents between meals, and lacked a hydration cart.
F0883: The facility failed to develop and implement policies and procedures for pneumococcal vaccinations, including education on refusal and documentation.
Report Facts
Resident census: 124
Residents dependent on staff for bathing: 7
Residents needing assistance of one or two staff to bath: 67
Residents dependent on staff for dressing: 1
Residents needing assistance of one or two staff to dress: 105
Residents dependent on staff to transfer: 15
Residents needing assistance of one or two staff to transfer: 58
Residents dependent on staff for toilet use: 30
Residents needing assistance of one or two staff to toilet: 69
Residents dependent on staff to eat: 3
Residents needing assistance of one or two staff to eat: 46
Residents frequently incontinent of bladder: 101
Residents frequently incontinent of bowel: 66
Residents in wheelchairs all or most of the time: 64
Residents with diagnosis of dementia: 44
Residents with current pressure injuries: 3
Residents receiving preventive skin care: 118
Residents receiving hospice services: 7
Residents receiving respiratory care: 45
Residents with contractures: 32
Residents on pain management program: 81
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 2, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident self-determination, notification of change in condition, environmental safety and cleanliness, and prevention of accidents involving residents.
Complaint Details
The complaint investigation revealed failures in promoting resident self-determination, notification of changes to legal representatives, environmental safety and cleanliness, and prevention of resident injury from hot liquids. The facility was found to have past noncompliance with corrective actions implemented for the burn injury prior to the survey.
Findings
The facility failed to promote resident self-determination regarding daily routines and preferences for three residents, failed to timely notify a resident's legal representative of medication changes, failed to maintain a clean, safe, and homelike environment with multiple maintenance and housekeeping deficiencies, and failed to prevent a second-degree burn injury to a resident caused by hot liquid due to inadequate supervision and safety measures.
Deficiencies (4)
Failed to promote resident self-determination for three residents regarding daily care preferences and activities.
Failed to timely notify Resident #2's legal representative of medication changes and diagnostic results.
Failed to maintain a clean, safe, homelike environment including offensive odors, broken handrails, peeling paint, unsecured cables, and lack of clean linens.
Failed to prevent an accident involving hot liquid causing a second-degree burn to Resident #1.
Report Facts
Residents reviewed: 13
Residents affected: 3
Burn wound measurements: 3
Burn wound measurements: 9.3
Burn wound measurements: 0.1
Burn wound measurements: 1
Burn wound measurements: 3
Burn wound measurements: 2.5
Burn wound measurements: 2.8
Coffee temperature: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Acknowledged being Resident #2's regular daytime nurse and discussed medication changes |
| Nursing Home Administrator | NHA | Provided facility policies, interviewed regarding deficiencies and corrective actions |
| Maintenance Director | MTD | Discussed facility maintenance issues and repair priorities |
| Housekeeping Supervisor | HSKS | Discussed housekeeping deficiencies and cleaning protocols |
| Dietary Manager | DM | Discussed hot beverage preparation and safety procedures |
| Certified Nurse Aide #2 | CNA | Interviewed about Resident #1 care and injury |
| Certified Nurse Aide #3 | CNA | Reported Resident #1 injury to nurse and described observations |
| Licensed Practical Nurse #4 | LPN | Described Resident #1 behavior and injury circumstances |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 2, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding resident self-determination, notification of change for a resident, environmental safety and cleanliness, and an accident involving a resident burn.
Complaint Details
The complaint investigation revealed failures in resident self-determination, notification of medication changes to a legal representative, environmental safety and cleanliness, and prevention of a burn injury to a resident. The burn injury was confirmed as a second-degree burn caused by hot liquid, with corrective actions implemented prior to the survey.
Findings
The facility failed to promote resident self-determination for three residents by not assessing or documenting their preferences, failed to notify a resident's legal representative timely about medication changes, failed to maintain a safe, clean, and homelike environment with multiple maintenance and housekeeping deficiencies, and failed to prevent a second-degree burn injury to a resident caused by hot liquid.
Deficiencies (4)
F 0561: The facility failed to promote resident self-determination by not assessing or documenting daily care preferences and showering schedules for residents #10, #4, and #13.
F 0580: The facility failed to timely notify Resident #2's legal representative of a medication change and diagnostic results.
F 0584: The facility failed to maintain a safe, clean, and homelike environment on the east side of the building, including offensive odors, broken handrails, soiled walls, peeling paint, unsecured cables, and lack of fresh linens.
F 0689: The facility failed to prevent an accident causing a second-degree burn to Resident #1 from hot liquid, and failed to provide adequate supervision to prevent such accidents.
Report Facts
Residents reviewed: 13
Residents affected: 3
Residents affected: 1
Residents affected: 6
Residents affected: 1
Burn wound size: 3
Burn wound size: 9.3
Burn wound size: 0.1
Temperature limit: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding shower schedules and resident care |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding shower schedules and maintenance delays |
| Registered Nurse #1 | RN | Interviewed regarding shower schedules and resident care |
| Nursing Home Administrator | NHA | Interviewed regarding facility policies, resident care, and corrective actions |
| Unit Nursing Manager | UNM | Interviewed regarding resident care and facility maintenance |
| Maintenance Director | MTD | Interviewed regarding facility repairs and maintenance priorities |
| Housekeeping Supervisor | HSKS | Interviewed regarding housekeeping practices and cleaning deficiencies |
| Dietary Manager | DM | Interviewed regarding hot beverage preparation and safety |
| Certified Nurse Aide #2 | CNA | Interviewed regarding resident burn incident and care |
| Certified Nurse Aide #3 | CNA | Interviewed regarding resident burn incident and care |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding resident behavior and burn incident |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, food service, and facility sanitation.
Findings
The facility was found deficient in multiple areas including failure to update resident care plans after falls, unsafe hot water temperatures, lack of medically related social services for discharge planning, medication administration errors, serving unpalatable and improperly timed meals, failure to provide snacks, and unsanitary food handling and storage practices.
Deficiencies (7)
Failed to update person-centered care plans to reflect changes in interventions after resident falls.
Failed to ensure water accessible to residents was maintained at safe temperatures in seven of 14 hallways.
Failed to provide medically related social services for discharge planning when requested by resident.
Medication error rate was 13.16% with five errors out of 38 opportunities observed.
Failed to serve palatable meals; residents reported food was hard, cold, tasteless, and portions were small.
Failed to serve meals and snacks at times consistent with resident preferences and posted mealtimes; meals were often late and snacks were not provided as needed.
Failed to maintain sanitary food handling and storage practices including improper hair restraints, raw eggs stored above ready-to-eat items, improper handwashing and glove use by dietary staff, and unlabeled/expired items in nourishment refrigerators.
Report Facts
Medication error rate: 13.16
Number of residents affected by hot water temperature issue: 7
Number of residents observed with meal service issues: 5
Number of residents affected by meal/snack timing issues: 136
Number of unlabeled/expired items observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error finding for failing to administer medications as ordered. |
| RN #1 | Registered Nurse | Involved in fall incident reporting and medication administration observations. |
| Director of Nursing | Director of Nursing | Provided interviews regarding care plan updates, medication administration expectations, and food service issues. |
| Administrator | Administrator | Provided interviews regarding incident reporting, food service expectations, and social services staffing. |
| District Dietary Manager | District Dietary Manager | Provided interviews regarding meal service, snack provision, and food handling practices. |
| Registered Dietitian | Registered Dietitian | Provided interviews regarding meal service timing, snack provision, and sanitation rounds. |
| Dietary Aide #1 | Dietary Aide | Observed with improper hair restraint in kitchen. |
| Dietary Aide #2 | Dietary Aide | Observed with improper handwashing and glove use. |
| Social Service Director | Social Service Director | Interviewed regarding lack of discharge planning services. |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 28, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, medication administration, food service, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to update resident care plans after falls, unsafe hot water temperatures, failure to provide medically related social services for discharge planning, medication errors exceeding 5%, serving unpalatable meals, late meal service and lack of snacks, and unsanitary food storage and preparation practices.
Deficiencies (7)
F 0657: The facility failed to update person-centered care plans to reflect changes in interventions after falls for Resident #84.
F 0689: The facility failed to ensure water accessible to residents was maintained at safe temperatures in seven of 14 hallways, with temperatures exceeding recommended limits.
F 0745: The facility failed to provide medically related social services for Resident #55 related to discharge planning and transfer requests.
F 0759: The facility failed to ensure medication error rates were below 5%, with five errors out of 38 opportunities observed for two residents.
F 0804: The facility failed to serve palatable meals to five residents, with complaints of hard French toast, cold food, and poor taste.
F 0809: The facility failed to provide meals at regular times consistent with posted mealtimes and resident preferences for 136 residents, and failed to provide snacks for residents who wanted to eat outside scheduled meal times.
F 0812: The facility failed to store and prepare foods under sanitary conditions including improper hair restraints, raw eggs stored above ready-to-eat items, improper handwashing and glove use by dietary staff, and unlabeled and expired items in nourishment refrigerators.
Report Facts
Medication error rate: 13.16
Hot water temperatures: 140
Residents affected by hot water temperature issue: 7
Residents affected by palatable meal issue: 5
Residents affected by meal/snack timing issue: 136
Unlabeled/expired items found: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error findings for failing to administer medications and improper medication cart handling |
| LPN #1 | Licensed Practical Nurse | Named in medication error findings for improper medication administration and documentation |
| RN #1 | Registered Nurse | Involved in fall incident reporting and medication administration observations |
| Dietary Aide #1 | Dietary Aide | Observed with improper hair restraint in kitchen |
| Dietary Aide #2 | Dietary Aide | Observed improper handwashing and glove use in kitchen |
| Assistant Dietary Manager | Assistant Dietary Manager | Interviewed regarding hair restraint policy and meal service |
| District Dietary Manager | District Dietary Manager | Interviewed regarding meal service, snack provision, and kitchen sanitation |
| Director of Nursing | Director of Nursing | Interviewed regarding fall care plan updates, medication administration expectations, and meal service issues |
| Administrator | Administrator | Interviewed regarding fall incident reporting, meal service expectations, and snack provision |
| Registered Dietitian | Registered Dietitian | Interviewed regarding meal quality, snack provision, and kitchen sanitation rounds |
Inspection Report
Census: 138
Deficiencies: 16
Date: Dec 18, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care, staffing, infection control, and other aspects of facility operation.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination, inadequate posting of state contact information, insufficient clean linens, failure to prevent and investigate abuse, inadequate assistance with activities of daily living, failure to provide person-centered activities, failure to maintain or improve resident mobility, unsafe environment with medical equipment plugged into non-medical power strips, multiple falls with major injuries, inadequate pain management, insufficient nursing staff, medication errors, improper medication storage, unpalatable food served at inappropriate temperatures, and ineffective quality assurance program.
Deficiencies (16)
Failure to promote resident self-determination and support resident rights to leave the facility at will.
Failure to post accurate state contact information and ombudsman contact information.
Failure to ensure clean linens including towels were available for resident use.
Failure to protect residents from sexual abuse and to investigate and monitor inappropriate sexual behaviors.
Failure to investigate and respond appropriately to allegations of potential abuse.
Failure to provide appropriate assistance with activities of daily living including meal assistance and nail care.
Failure to provide person-centered activities tailored to resident preferences and needs.
Failure to provide appropriate care to maintain or improve range of motion and mobility for residents with limited mobility.
Failure to ensure resident environment was free from accident hazards including medical devices plugged into non-medical grade power strips and use of space heaters in resident areas. Failure to prevent multiple falls with major injuries.
Failure to provide safe and appropriate pain management including thorough pain assessments and non-pharmaceutical interventions.
Failure to provide sufficient nursing staff with appropriate competencies and skills to meet resident care needs, resulting in delayed call light response, inadequate assistance with ADLs, and insufficient meal assistance.
Failure to ensure medication error rate was below 5%, including late insulin administration and administration of medication without physician order.
Failure to ensure drugs and biologicals were stored in locked compartments and not left unattended on medication carts or nurse stations.
Failure to serve food that was palatable, attractive, and at safe and appetizing temperatures.
Failure to implement an effective quality assurance program to identify and address facility compliance concerns, resulting in repeated resident falls and injuries and other quality issues.
Failure to ensure infection prevention and control practices including proper care and storage of oxygen equipment and cleaning of call light cords and bathroom environment.
Report Facts
Resident census: 138
Falls: 26
Medication error rate: 8
Staffing: 9
Staffing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed administering insulin late and applying medication without order |
| RN #3 | Registered Nurse | Observed keeping resident near nurse's cart and interviewed about 1:1 care |
| DON | Director of Nursing | Interviewed about restorative program, falls, medication administration, and QAPI |
| NHA | Nursing Home Administrator | Interviewed about staffing, QAPI, falls, and infection control |
| MTD | Maintenance Director | Interviewed about space heaters, call light cords, and infection control |
| CNA #7 | Certified Nurse Aide | Interviewed about staffing shortages |
| RN #1 | Registered Nurse | Interviewed about staffing and resident care |
| RN #5 | Registered Nurse | Interviewed about staffing and pain management |
| LPN #6 | Licensed Practical Nurse | Interviewed about resident pain and care |
Inspection Report
Census: 138
Deficiencies: 15
Date: Dec 18, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, staffing, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including resident rights, safety, staffing, pain management, medication administration, food quality, infection control, and quality assurance. Significant concerns included repeated resident falls with injury, inadequate staffing, failure to provide restorative services, medication errors, and poor food palatability.
Deficiencies (15)
F 0561: The facility failed to honor resident self-determination and choice related to leaving the facility without unnecessary restrictions or filing missing person reports.
F 0574: The facility failed to post accurate and complete state regulatory and ombudsman contact information for residents.
F 0584: The facility failed to ensure clean linens, including towels and washcloths, were consistently available for resident use.
F 0600: The facility failed to protect residents from sexual abuse by Resident #43 and failed to investigate and implement effective interventions.
F 0610: The facility failed to respond appropriately to allegations of potential abuse involving Resident #388 and failed to investigate or document incidents.
F 0677: The facility failed to provide appropriate assistance with activities of daily living and proper nail care for Resident #22.
F 0679: The facility failed to provide person-centered activities that met the needs of Resident #46, including accommodations for visual impairment.
F 0688: The facility failed to provide restorative services and passive range of motion to Resident #19 with limited mobility and contractures.
F 0689: The facility failed to ensure resident safety and prevent falls, resulting in immediate jeopardy due to Resident #33 sustaining 26 falls with major injuries.
F 0759: 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 insufficient assistance.
F 0759: The facility failed to ensure medications were administered timely and only with physician orders, resulting in medication errors for Residents #59 and #86.
F 0761: The facility failed to ensure medications and biologicals were stored in locked compartments and not left unattended.
F 0804: The facility failed to consistently serve food that was palatable, attractive, and at appropriate temperatures.
F 0865: The facility failed to implement an effective quality assurance program to identify and address quality concerns including falls, staffing, restorative care, pain management, and food quality.
F 0880: The facility failed to ensure infection control practices were followed including proper care and storage of oxygen equipment and cleaning of call light cords and bathroom environment.
Report Facts
Resident census: 138
Falls: 26
Medication error rate: 8
Staffing: 9
Staffing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication error and medication administration observation |
| RN #3 | Registered Nurse | Observed providing 1:1 care to Resident #33 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including restorative care, falls, medication, staffing, and QAPI |
| NHA | Nursing Home Administrator | Interviewed regarding staffing, QAPI, and facility operations |
| MTD | Maintenance Director | Interviewed regarding infection control and environmental concerns |
| DM | Dietary Manager | Interviewed regarding food temperature and palatability |
| DS | Dietary Supervisor | Interviewed regarding food temperature and palatability |
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