Inspection Reports for
Pearl Street Health and Rehabilitation Center
CO, 80113
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
208% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged misappropriation of property and exploitation of a resident by a facility employee.
Complaint Details
The complaint investigation was substantiated with findings that an activity assistant financially exploited Resident #1 by obtaining the resident's vehicle title and credit card information without proper consent. The facility reported the incident to adult protection services, the ombudsman, and the police. The employee was terminated and the case remains open.
Findings
The facility failed to protect Resident #1 from financial exploitation and misappropriation of property by an activity assistant. The investigation revealed that the employee took control of the resident's vehicle title and credit card information, resulting in unauthorized charges and loss of property.
Deficiencies (1)
F 0602: The facility failed to protect each resident from the wrongful use of the resident's belongings or money, resulting in minimal harm or potential for actual harm to a few residents.
Report Facts
Amount of money withdrawn and given to employee: 1000
Insurance charge on credit card: 400
Resident age: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA #1 | Activity Assistant | Named as the employee who financially exploited Resident #1. |
| NHA | Nursing Home Administrator | Interviewed regarding the incident and facility policies. |
| SSD | Social Services Director | Discovered the incident and reported findings. |
| CNA #1 | Certified Nurse Aide | Interviewed about staff training and policies. |
| RN #1 | Registered Nurse | Interviewed about staff training and policies. |
Inspection Report
Routine
Deficiencies: 13
Date: Sep 11, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide free personal hygiene items such as soap, inadequate cleaning and maintenance of resident rooms and shower rooms, failure to protect residents from abuse, failure to notify appropriate authorities of significant mental health changes, unsafe smoking practices, incomplete fall care plans, medication errors, improper medication storage and labeling, infection control lapses including failure to follow enhanced barrier precautions and hand hygiene, unsafe and unsanitary shower equipment and rooms, and inadequate ventilation in shower rooms.
Deficiencies (13)
Facility failed to provide routine personal hygiene items such as hand soap free of charge to residents.
Failed to maintain a clean, comfortable, and homelike environment including unclean window blinds, broken bed footboard, missing bath towels, and strong odors in resident rooms and shower rooms.
Failed to protect residents #27 and #43 from physical abuse by Resident #48.
Failed to notify state mental health agency promptly after significant change in Resident #7's mental condition.
Failed to ensure environment was free from accident hazards including unsafe smoking practices and incomplete fall care plans for Resident #5.
Medication error rate exceeded 5%, including wrong aspirin form and incorrect paliperidone dose.
Failed to ensure all drugs and biologicals were properly labeled and expired OTC medications were present in medication carts.
Failed to ensure food was stored, prepared, and served under sanitary conditions including expired and unlabeled food items in walk-in refrigerator.
Failed to provide specialized rehabilitative services as ordered for Resident #74 in a timely manner.
Failed to maintain an infection control program including failure to follow enhanced barrier precautions during resident care and transfer, and failure to perform hand hygiene during medication administration.
Failed to maintain shower gurney pad in good repair and clean according to instructions; pad had exposed wet foam.
Failed to maintain shower rooms in safe, sanitary, and working condition including broken drain covers, wet towels on floor, missing caulking with black substance, stained tubs, dripping shower heads, and unlabeled cleaning chemicals.
Failed to ensure adequate ventilation in two shower rooms; ventilation fan covers were dusty and fans were not operational.
Report Facts
Medication error rate: 8
Residents interviewed: 39
Falls: 2
Cracks in shower gurney pad: 20
Minutes for chemical contact time: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #48 | Resident | Named in abuse and unsafe smoking findings |
| Resident #27 | Resident | Named in abuse findings |
| Resident #43 | Resident | Named in abuse findings |
| CNA #5 | Certified Nurse Aide | Observed cleaning shower gurney pad |
| LPN #2 | Licensed Practical Nurse | Observed medication administration with errors |
| RN #2 | Registered Nurse | Observed medication administration and hand hygiene failures |
| NHA | Nursing Home Administrator | Interviewed regarding multiple findings including abuse, environment, and infection control |
| MTD | Maintenance Director | Interviewed regarding facility maintenance and shower room conditions |
| RCR | Regional Clinical Resource | Interviewed regarding medication errors, infection control, and abuse findings |
Inspection Report
Routine
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing care by qualified persons according to each resident's written plan of care, specifically focusing on post-fall assessments for selected residents.
Findings
The facility failed to ensure that post-fall assessments were completed timely and documented by a qualified registered nurse for four residents (#2, #5, #6, and #7). The assessments were either delayed, undocumented, or performed by licensed practical nurses without proper RN documentation. The facility provided education and an action plan to correct these deficiencies.
Deficiencies (1)
Failure to ensure post-fall assessments were completed timely by a qualified person and documented in the medical record for Residents #2, #5, #6, and #7.
Report Facts
Residents affected: 4
Sample residents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in findings for failing to document assessments for Residents #2, #6, and #7 |
| LPN #1 | Licensed Practical Nurse | Performed initial assessments for Resident #2 |
| LPN #2 | Licensed Practical Nurse | Heard Resident #5's wife calling for help and documented fall investigation |
| Director of Nursing | Director of Nursing (DON) | Assessed Resident #5 after fall but delayed documentation; involved in education and follow-up |
| Quality Mentor | Quality Mentor | Provided education and action plan regarding post-fall assessment documentation |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding facility policies and staff responsibilities |
Inspection Report
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with the facility's policies and procedures related to post-fall assessments and to ensure that care was provided by qualified persons according to each resident's written plan of care.
Findings
The facility failed to ensure that post-fall assessments were completed timely by a qualified registered nurse and documented in the medical records for four residents (#2, #5, #6, and #7). The facility provided education and an action plan to improve documentation and assessment practices.
Deficiencies (1)
F 0659: The facility failed to ensure that post-fall assessments were completed timely by a registered nurse and documented for four residents (#2, #5, #6, and #7).
Report Facts
Residents in sample: 11
Residents with deficient post-fall assessments: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in findings for failure to document post-fall assessments |
| LPN #1 | Licensed Practical Nurse | Performed initial assessments for Resident #2 |
| LPN #2 | Licensed Practical Nurse | Performed initial assessments for Resident #5 |
| Director of Nursing | Director of Nursing | Named in delayed documentation of Resident #5's assessment |
| Quality Mentor | Quality Mentor | Provided education and action plan for assessment documentation |
| NHA | Nursing Home Administrator | Interviewed regarding assessment procedures |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 4, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify resident representatives of significant changes in condition, failure to maintain a safe and homelike environment, and failure to protect residents from abuse.
Complaint Details
The complaint investigation substantiated that the facility failed to notify resident representatives of hospitalizations and significant condition changes for Residents #7 and #8. It also substantiated failure to maintain a clean and homelike environment and failure to prevent physical abuse incidents involving Residents #1, #2, and #5.
Findings
The facility failed to notify resident representatives of significant changes in condition for two residents, failed to maintain a safe, clean, and homelike environment in multiple hallways, and failed to protect three residents from physical abuse by other residents. Multiple interviews, record reviews, and observations substantiated these deficiencies.
Deficiencies (3)
Failure to notify resident representatives of significant changes in condition for Residents #7 and #8.
Failure to provide a safe, clean, sanitary, and homelike environment throughout the facility, including unclean resident rooms, stained linens and curtains, and strong odors.
Failure to protect Residents #1, #2, and #5 from physical abuse by other residents, including incidents of punching and hair pulling.
Report Facts
Residents reviewed: 12
Residents affected: 2
Residents affected: 3
BIMS score: 15
BIMS score: 12
15-minute checks: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in failure to notify resident representative finding |
| NHA | Nursing Home Administrator | Provided facility policies and interviewed regarding deficiencies |
| SSD | Social Services Director | Interviewed regarding resident representative notification and abuse investigations |
| RNC | Regional Nurse Consultant | Interviewed regarding notification procedures and facility expectations |
| LPN #2 | Licensed Practical Nurse | Witnessed and intervened in resident-to-resident physical abuse incident |
| RN #1 | Registered Nurse | Assessed residents after abuse incidents |
| CNA #2 | Certified Nurse Aide | Witnessed hair pulling incident and provided written statement |
| CNA #1 | Certified Nurse Aide | Interviewed about resident behavior and interventions |
| CNA #3 | Certified Nurse Aide | Interviewed about resident behavior and interventions |
| DON | Director of Nursing | Interviewed about abuse prevention and resident behavior management |
| HK #1 | Housekeeper | Interviewed regarding cleaning practices and environment maintenance |
| MTD | Maintenance Director | Interviewed regarding cleaning and maintenance of resident rooms |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to maintain a safe, clean, and homelike environment, prevent resident abuse, and protect residents from exploitation and misappropriation of property.
Complaint Details
The complaint investigation revealed substantiated incidents of sexual abuse, physical abuse, and financial exploitation involving multiple residents and staff. Resident #13 was involved in sexual and physical abuse incidents against other residents. Resident #7 was financially exploited by a housekeeper who was terminated following the investigation.
Findings
The facility was found to have multiple deficiencies including failure to maintain cleanliness and odor control, failure to prevent sexual and physical abuse among residents, inadequate monitoring and care planning for a resident with a history of aggression, and failure to protect a resident from financial exploitation by a staff member.
Deficiencies (4)
Failure to provide a safe, clean, sanitary, and comfortable environment including odor control and cleanliness of resident rooms and common areas.
Failure to prevent sexual abuse of Resident #12 by Resident #13 and physical abuse of Residents #14 and #23 by Resident #13.
Failure to implement timely care plan interventions and monitoring for Resident #13 with known history of violent aggression.
Failure to protect Resident #7 from exploitation and misappropriation of property by a staff member who took $5,060 from the resident.
Report Facts
Residents reviewed for abuse: 23
Residents affected by abuse: 3
Amount of money taken: 5060
Number of money transfers: 11
Dates of money transfers: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Named in findings related to cleaning deficiencies |
| Housekeeper #2 | Housekeeper | Terminated for financial exploitation of Resident #7 |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies and abuse incidents |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding odor control and resident monitoring |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding odor control and resident monitoring |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding resident care and cleaning |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding resident aggression and abuse incidents |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding resident aggression and abuse incidents |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding abuse investigations and financial exploitation |
| Social Services Director | Social Services Director | Interviewed regarding abuse investigations |
| Corporate Nurse Consultant | Corporate Nurse Consultant | Interviewed regarding abuse investigations and facility policies |
| Maintenance Director | Maintenance Director | Interviewed regarding facility repairs and odor control |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, treatment, and facility environment at Wellsprings Care Center.
Findings
The facility failed to ensure residents received scheduled personal hygiene care, failed to monitor and document weight as ordered for a resident with heart failure, and failed to maintain a safe, clean, and comfortable environment including proper housekeeping and fire safety measures.
Deficiencies (3)
F 0677: The facility failed to ensure Resident #1, dependent on staff for bathing, received scheduled showers, providing only five showers out of 16 opportunities without proper documentation of refusals or follow-up.
F 0684: The facility failed to weigh Resident #6 weekly per physician orders and did not update the care plan to include new weight monitoring interventions related to atrial fibrillation and heart failure.
F 0921: The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not keeping the second floor smoking patio free of debris, not properly disposing of outdoor refuse, and not removing long-standing stains from a resident's room floor.
Report Facts
Showers received: 5
Showers scheduled: 16
Weight gain: 20.2
Weight gain: 12.2
Wooden pallets: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding shower documentation and procedures for Resident #1. |
| Certified Nurse Aide #1 | CNA | Interviewed about shower documentation and follow-up for Resident #1. |
| Certified Nurse Aide #2 | CNA | Interviewed about shower refusal documentation for Resident #1. |
| Certified Nurse Aide #3 | CNA | Interviewed about fire blanket knowledge on smoking patio. |
| Certified Nurse Aide #4 | CNA | Interviewed about fire blanket location and use. |
| Director of Nursing | DON | Interviewed about shower documentation and care plan updates. |
| Quality Mentor | QM | Provided facility policies and interviewed about shower and weight monitoring expectations. |
| Nursing Home Administrator | NHA | Interviewed about care plan reviews and weight monitoring. |
| Housekeeper #1 | HSK | Interviewed about cleaning and stain removal processes. |
| Housekeeping Supervisor | HSKS | Interviewed about cleaning schedules and stain removal procedures. |
| Maintenance Supervisor | MS | Interviewed about facility maintenance including swamp cooler replacement and outdoor pallets. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards for care and environment at Wellsprings Care Center, including resident care, treatment, and facility safety.
Findings
The facility failed to ensure residents received scheduled personal hygiene care, specifically Resident #1 did not receive all scheduled showers. Resident #6 was not weighed weekly as ordered, and the care plan was not updated accordingly. Environmental deficiencies included debris and poor visibility of fire safety equipment on the smoking patio, outdoor refuse area clutter, and long-standing stains in a resident's room.
Deficiencies (3)
Failed to ensure Resident #1 received scheduled showers and personal hygiene assistance.
Failed to ensure Resident #6 was weighed weekly per physician orders and care plan was not updated to reflect weight monitoring interventions.
Failed to maintain a safe, functional, sanitary, and comfortable environment including debris on smoking patio, poor visibility of fire blanket, outdoor refuse area clutter, and long-standing stains on resident room floor.
Report Facts
Showers received: 5
Weight gain: 20.2
Weight gain: 12.2
Wooden pallets: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding shower documentation and procedures for Resident #1. |
| Certified Nurse Aide #1 | CNA | Interviewed about shower documentation and follow-up for Resident #1. |
| Certified Nurse Aide #2 | CNA | Interviewed about shower refusal documentation and procedures. |
| Certified Nurse Aide #3 | CNA | Interviewed about fire blanket knowledge on smoking patio. |
| Certified Nurse Aide #4 | CNA | Interviewed about fire blanket knowledge and staffing agency status. |
| Director of Nursing | DON | Interviewed regarding shower documentation and weight monitoring processes. |
| Quality Mentor | QM | Provided facility policies and interviewed about shower and weight monitoring expectations. |
| Nursing Home Administrator | NHA | Interviewed about care plan updates and weight monitoring. |
| Housekeeper #1 | HSK | Interviewed about cleaning stains on floors. |
| Housekeeping Supervisor | HSKS | Interviewed about cleaning procedures and stain removal. |
| Maintenance Supervisor | MS | Interviewed about ceiling duct placement and wooden pallets near refuse area. |
| Regional MDS Coordinator | RMC | Interviewed with DON, QM, and NHA about weight monitoring. |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, specifically focusing on sanitation and rodent infestation issues.
Findings
The facility failed to maintain a clean and sanitary homelike environment on three of four units, with multiple observations of soiled walls, floors, bedding, and presence of mouse droppings. Residents reported seeing mice and dissatisfaction with housekeeping. Pest control efforts were ongoing but housekeeping was not adequately cleaning mouse droppings and soiled areas.
Deficiencies (2)
Failure to ensure residents experienced a clean and sanitary homelike environment with living spaces free from odors, dirt, debris, and soiled areas.
Failure to ensure mouse droppings were removed and surfaces properly sanitized from possible rodent contamination.
Report Facts
Residents affected: Some residents affected by the deficiencies
Date of survey completed: Oct 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Interviewed regarding cleaning practices and mouse droppings |
| Maintenance Director | Maintenance Director | Interviewed about pest control and housekeeping practices |
| Corporate Consultant #1 | Corporate Consultant | Provided Homelike Environment policy and confirmed mattress replacement |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 14, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration standards, infection prevention and control, sanitation, safety, and environmental conditions at Wellsprings Care Center.
Findings
The facility failed to maintain medication error rates below 5%, with a medication error rate of 17.24%. Deficiencies were found in medication administration accuracy, infection control practices, housekeeping, pest control, sanitation, and environmental cleanliness. Issues included improper medication dosing, failure to notify physicians of missed medications, unclean high-touch surfaces, empty hand sanitizer dispensers, uncovered resident laundry, pest infestations, unsanitary dumpster areas, and dirty resident rooms and common areas.
Deficiencies (4)
Medication error rate was 17.24%, exceeding the 5% threshold, including incorrect dosages and failure to notify physicians of missed medications.
Garbage and refuse were not properly disposed of; dumpster lids were open and garbage was found around dumpsters attracting pests.
Failed to maintain an effective infection prevention and control program, including inadequate cleaning of high-touch surfaces, improper disinfectant use, lack of hand hygiene by housekeeping staff, empty hand sanitizer dispensers, failure to provide hand hygiene to residents before meals, and uncovered resident laundry during transport.
Facility environment was unsafe, unsanitary, and uncomfortable, with debris and food in resident rooms, dining rooms, hallways, elevator, and kitchen; presence of mice and mouse droppings; dumpsters overflowing and open; and cigarette butts at the entrance.
Report Facts
Medication error rate: 17.24
Medication errors: 5
Medication opportunities: 29
Hand sanitizer dispensers empty: 8
Hand sanitizer dispensers empty: 5
Rodent size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed administering incorrect medication doses and failing to notify physician of missed medications. |
| LPN #3 | Licensed Practical Nurse | Observed administering incorrect medications and dosages. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration policies and procedures. |
| Clinical Nurse Consultant | Clinical Nurse Consultant (CNC) | Interviewed regarding medication order verification and infection control. |
| Maintenance Director | Maintenance Director | Interviewed about dumpster area maintenance and pest control. |
| Dietary Manager | Dietary Manager (DM) | Interviewed about dumpster area cleanliness and staff education. |
| Housekeeping Staff #1 | Housekeeper | Observed failing to clean high-touch surfaces and perform hand hygiene. |
| Housekeeping Staff #2 | Housekeeper | Observed cleaning resident rooms inadequately and interviewed about cleaning practices. |
| Housekeeping/Laundry/Maintenance Manager | Housekeeping/Laundry/Maintenance Manager (HLM) | Interviewed about cleaning procedures and expectations. |
| Maintenance Director (MTD) | Maintenance Director and Housekeeping/Laundry Supervisor | Interviewed about housekeeping responsibilities and cleaning frequency. |
| Social Services Assistant | Social Services Assistant (SSA) | Interviewed about resident room cleanliness concerns. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed about facility cleaning, housekeeping staffing, and training. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 14, 2024
Visit Reason
The inspection was conducted due to complaints regarding resident abuse, bed hold notification failures, dialysis care communication, medication errors, medication storage and labeling, food safety and sanitation, garbage disposal, infection control, and facility environment concerns.
Complaint Details
The investigation was complaint-driven based on allegations of resident abuse, medication errors, infection control issues, and environmental safety concerns. Multiple incidents of resident-to-resident abuse were substantiated. Other complaints regarding facility practices and environment were confirmed through observations and interviews.
Findings
The facility was found to have multiple deficiencies including failure to prevent resident-to-resident physical abuse, failure to provide proper bed hold notification, incomplete dialysis communication, medication errors including incorrect dosages and failure to notify physicians, improper medication storage and labeling, unsanitary food preparation and storage conditions, improper garbage disposal attracting pests, inadequate infection control practices including poor housekeeping and hand hygiene, and an unsafe, unsanitary, and uncomfortable environment with pest infestations and debris throughout the facility.
Deficiencies (9)
F0600: The facility failed to protect residents from physical abuse by Resident #49 against Residents #27, #39, #212, and #6, substantiated by investigations and staff interviews.
F0625: The facility failed to provide Resident #27 with appropriate bed hold notification when transferred to the hospital on two occasions.
F0698: The facility failed to ensure dialysis communication forms were completed by the dialysis center for Resident #8, resulting in incomplete communication.
F0759: The facility had a medication error rate of 17.24%, including underdosing, failure to administer ordered medications, and administering incorrect medications or dosages.
F0761: The facility failed to properly label and store medications on a medication cart, including unlabeled insulin pens, unattended medications, improper disposal of crushed medications, and unclean medication carts.
F0812: The facility failed to maintain sanitary food preparation and storage, including staff not wearing hair restraints, freezer temperatures above recommended levels causing thawed foods, rodent contamination in dry storage, improper hand hygiene and glove use by kitchen staff, and undated food in nourishment refrigerators.
F0814: The facility failed to ensure dumpster lids were closed and the dumpster area was free of trash and debris, resulting in rodent presence and unsanitary conditions.
F0880: The facility failed to maintain an effective infection control program, including inadequate cleaning of high-touch surfaces, improper disinfectant use, failure of housekeeping staff to perform hand hygiene, empty hand sanitizer dispensers, failure to offer residents hand hygiene before meals, and uncovered resident laundry during transport.
F0921: The facility failed to provide a safe, clean, and comfortable environment, including debris and food in resident rooms, hallways, dining rooms, elevator, open dumpsters with trash on the ground, kitchen rodent droppings, and cigarette butts at the entrance.
Report Facts
Medication error rate: 17.24
Dialysis communication incomplete forms: 13
Residents affected by abuse: 4
Residents reviewed for abuse: 6
Residents reviewed for bed hold policy: 2
Hand sanitizer dispensers empty: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed administering incorrect medication doses and failing to notify physician. |
| LPN #3 | Licensed Practical Nurse | Administered incorrect medication dose of Methadone and medication substitution without physician order. |
| CK #1 | Cook | Observed not wearing beard net and improper hand hygiene during food preparation. |
| CK #2 | Cook | Observed not wearing beard net and improper glove use during food preparation. |
| DM | Dietary Manager | Interviewed regarding food safety, freezer temperature, rodent contamination, and dumpster sanitation. |
| HSK #1 | Housekeeper | Observed failing to perform hand hygiene and clean high-touch surfaces. |
| HSK #2 | Housekeeper | Observed failing to clean high-touch surfaces and perform hand hygiene. |
| MTD | Maintenance Director / Housekeeping Supervisor | Interviewed about housekeeping responsibilities and facility cleanliness. |
| NHA | Nursing Home Administrator | Interviewed regarding policies, deficiencies, and corrective actions. |
| SSA | Social Services Assistant | Interviewed regarding resident room cleanliness and resident concerns. |
| CNC | Corporate Nurse Consultant | Interviewed regarding medication administration and infection control practices. |
| IDON | Interim Director of Nursing | Interviewed regarding infection control and hand hygiene practices. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 3, 2022
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements, including investigation of an abuse allegation and evaluation of food safety practices.
Findings
The facility failed to timely report an allegation of staff-to-resident abuse within the required two-hour window, allowed the alleged perpetrator to return to work before completing an investigation, and failed to maintain proper kitchen sanitation including inadequate dish machine sanitizer concentration and incomplete refrigerator and freezer temperature logs.
Deficiencies (4)
Failed to timely report suspected staff-to-resident abuse to the state survey agency within two hours of the allegation.
Failed to protect a resident from further potential abuse by allowing the alleged perpetrator to return to work before completing an investigation.
Failed to maintain proper kitchen sanitation by continuing to wash dishes using a low temperature dish machine without proper sanitizer concentration.
Failed to maintain a log of refrigerator and freezer temperatures for several days.
Report Facts
Time delay in reporting abuse allegation: 5
Sanitizer concentration: 0
Sanitizer concentration logged: 100
Dishwasher temperature requirement: 120
Refrigerator temperature: 41
Freezer temperature: 0
Dates missing temperature logs: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in abuse allegation involving inappropriate hand gesture and yelling at Resident #3 |
| RN #1 | Registered Nurse | Received abuse allegation report from Resident #3 and sent CNA #1 home |
| Director of Nursing | Director of Nursing | Responsible for investigation and reporting of abuse allegation; did not report within required timeframe |
| Social Services Director | Social Services Director | Responsible for conducting resident interviews and follow-up during abuse investigation |
| Administrator | Administrator | Notified late of abuse allegation; authorized CNA #1 to return to work before investigation completed |
| DA #1 | Dietary Aide | Failed to ensure proper sanitizer concentration in dish machine and inaccurately logged sanitizer levels |
| Account Manager | Account Manager | Responsible for oversight of kitchen staff and temperature logs |
| District Manager | District Manager | Provided education to kitchen staff on sanitizer and temperature log procedures |
| Cook | Cook | Responsible for completing refrigerator and freezer temperature logs; acknowledged missed logs due to short staffing |
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