Inspection Reports for
Pearl Street Health and Rehabilitation Center
CO, 80113
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
33 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
535% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of property and exploitation of a resident by a facility employee.
Complaint Details
The complaint investigation found that AA #1 financially exploited Resident #1 by obtaining the resident's van title and credit card information, resulting in unauthorized charges and loss of property. The facility reported the incident to Adult Protection Services, the ombudsman, and police. AA #1 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 (AA #1), who took the resident's van title and money without proper consent. The facility took immediate actions including suspending the employee and reporting to authorities.
Deficiencies (1)
Failure to protect each resident from wrongful use of the resident's belongings or money.
Report Facts
Money withdrawn: 1000
Insurance charge: 400
Resident age: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA #1 | Activity Assistant | Employee who financially exploited Resident #1. |
| NHA | Nursing Home Administrator | Interviewed AA #1 and reported the incident to authorities. |
| SSD | Social Services Director | Discovered the incident and reported findings. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding abuse training and staff policies. |
| RN #1 | Registered Nurse | Interviewed regarding abuse training and staff policies. |
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: 9
Date: Sep 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, safety, infection control, medication administration, and environmental conditions.
Findings
The facility failed to maintain a clean, safe, and homelike environment, including issues with unclean resident rooms, lack of bath towels in shower rooms, unsafe smoking practices, incomplete fall care plans, medication errors, inadequate infection control practices, unsafe and unsanitary shower rooms, and insufficient ventilation in shower areas.
Deficiencies (9)
Failed to ensure Resident #4's window blinds and walls were cleaned and maintained and the resident's bed was in good condition.
Failed to ensure bath towels were available for resident use in shower rooms.
Failed to ensure residents' rooms were free from debris and odors and appropriate personal hygiene items were available.
Failed to ensure the environment was free of accident hazards and provided adequate supervision to prevent accidents for three residents.
Failed to ensure medication error rates were less than five percent; medication error rate was 8%.
Failed to provide and implement an infection prevention and control program, including failure to follow enhanced barrier precautions and hand hygiene.
Failed to ensure the first floor north shower gurney pad was smooth, cleanable, in good repair, and cleaned according to manufacturing instructions.
Failed to ensure the residents' shower rooms were maintained in a safe, sanitary and working condition.
Failed to ensure adequate outside ventilation by means of windows or mechanical ventilation for two shower rooms.
Report Facts
Medication error rate: 8
Number of cracks in shower gurney pad: 20
Number of cracks in shower gurney pad headrest: 8
Number of washcloths on linen rack: 15
Number of washcloths on linen rack: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed administering medications with errors and improper hand hygiene |
| LPN #3 | Licensed Practical Nurse | Observed administering medications without proper hand hygiene |
| CNA #4 | Certified Nurse Aide | Observed assisting Resident #49 without donning gowns during transfer |
| CNA #5 | Certified Nurse Aide | Observed cleaning shower gurney pad improperly and reporting issues |
| MTD | Maintenance Director | Interviewed regarding maintenance issues and shower gurney pad |
| NHA | Nursing Home Administrator | Provided policies and interviewed regarding facility conditions and compliance |
| RCR | Regional Clinical Resource | Interviewed regarding infection control and smoking safety |
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: 6
Date: Sep 11, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, environment, infection control, medication administration, and facility maintenance.
Findings
The facility failed to maintain a clean, safe, and homelike environment, ensure proper infection control practices including enhanced barrier precautions and hand hygiene, maintain safe and sanitary shower rooms and equipment, and ensure accurate medication administration. Deficiencies were noted in environmental cleanliness, resident safety interventions, medication error rates, infection prevention, and facility maintenance.
Deficiencies (6)
F 0584: The facility failed to provide a clean, comfortable, and homelike environment including unclean window blinds, walls, broken bed parts, lack of bath towels in shower rooms, and rooms with debris, odors, and missing hygiene items.
F 0689: The facility failed to ensure the environment was free from accident hazards and provide adequate supervision to prevent accidents for three residents, including failure to reassess smoking safety and update fall care plans.
F 0759: The facility failed to ensure medication error rates were less than 5%, with an 8% error rate due to incorrect medication administration.
F 0880: The facility failed to maintain an infection control program by not following enhanced barrier precautions for residents with indwelling devices and failing to perform hand hygiene consistently during medication administration.
F 0921: The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not properly maintaining and cleaning the shower gurney pad and shower rooms, including exposed wet foam, broken drain covers, stains, and black substances on walls.
F 0923: The facility failed to ensure adequate outside ventilation in two shower rooms due to non-operational ventilation fans covered with dust.
Report Facts
Medication error rate: 8
Medication administration opportunities: 25
Cracks in shower gurney pad: 20
Cracks in shower gurney pad headrest: 8
Washcloths on linen rack: 15
Washcloths on linen rack: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed medication administration with errors and hand hygiene failures |
| LPN #3 | Licensed Practical Nurse | Observed medication administration with hand hygiene failures |
| CNA #4 | Certified Nurse Aide | Observed assisting Resident #49 without proper enhanced barrier precautions |
| CNA #5 | Certified Nurse Aide | Observed cleaning shower gurney pad improperly and reporting maintenance issues |
| MTD | Maintenance Director | Responsible for maintenance and housekeeping oversight; acknowledged issues with shower equipment and ventilation |
| NHA | Nursing Home Administrator | Provided policies and interviewed regarding facility deficiencies and corrective actions |
| RCR | Regional Clinical Resource | Interviewed regarding infection control, medication errors, and resident care |
Inspection Report
Routine
Deficiencies: 12
Date: Sep 11, 2025
Visit Reason
Routine inspection of Wellsprings Care Center to assess compliance with regulatory requirements including resident care, safety, environment, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide free personal hygiene items, inadequate cleaning and maintenance of resident rooms and shower areas, failure to protect residents from abuse, failure to notify appropriate authorities of significant mental health changes, unsafe smoking practices, medication errors, improper medication storage and labeling, inadequate infection control practices including failure to follow enhanced barrier precautions and hand hygiene, and environmental safety issues such as broken shower equipment and poor ventilation.
Deficiencies (12)
F0571: Facility failed to ensure residents were not charged for personal hygiene items covered by Medicare or Medicaid, including hand soap which residents had to purchase themselves.
F0584: Facility failed to maintain a clean, comfortable, and homelike environment including unclean window blinds, broken bed parts, lack of bath towels in shower rooms, and rooms with debris, odors, and missing hygiene items.
F0600: Facility failed to protect residents #27 and #43 from physical abuse by resident #48 and failed to update care plans and implement interventions to prevent further abuse.
F0646: Facility failed to notify the state mental health agency promptly after a significant change in Resident #7's mental condition requiring psychiatric hospitalization.
F0689: Facility failed to ensure safe environment by not reassessing residents #48 and #68 for safe smoking, inconsistent implementation of fall interventions for Resident #5, and failure to update fall care plan after falls.
F0759: Facility failed to ensure medication error rate was less than 5%, with errors including wrong aspirin form and incorrect paliperidone dose.
F0761: Facility failed to ensure all drugs and biologicals were properly labeled, stored, and not expired in medication carts.
F0812: Facility failed to ensure food was stored, prepared, and served under sanitary conditions including expired and unlabeled foods in the walk-in refrigerator.
F0825: Facility failed to ensure Resident #74 received ordered specialized rehabilitative therapy services in a timely manner after admission.
F0880: Facility failed to maintain an infection control program including failure to follow enhanced barrier precautions during care and transfer of residents with indwelling devices, and failure to perform hand hygiene consistently during medication administration.
F0921: Facility failed to provide a safe, functional, sanitary, and comfortable environment including a shower gurney pad with exposed wet foam, unclean shower rooms with broken drain covers, mold-like substances, and leaking shower heads.
F0923: Facility failed to ensure adequate outside ventilation in shower rooms due to non-operational ventilation fans with dirty covers.
Report Facts
Medication error rate: 8
Residents interviewed: 5
Residents affected: 39
Falls: 4
Cracks in shower gurney pad: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed medication administration with hand hygiene failures. |
| LPN #3 | Licensed Practical Nurse | Observed medication administration with hand hygiene failures. |
| CNA #5 | Certified Nurse Aide | Observed cleaning shower gurney pad and reported maintenance issues. |
| NHA | Nursing Home Administrator | Interviewed regarding multiple deficiencies including abuse, infection control, and environment. |
| RCR | Regional Clinical Resource | Interviewed regarding infection control, medication errors, and abuse investigations. |
| MTD | Maintenance Director | Interviewed regarding environmental maintenance and shower room issues. |
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: 3
Date: Jun 4, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify resident representatives of significant changes, failure to maintain a safe and clean environment, and failure to prevent resident-to-resident abuse.
Complaint Details
The complaint investigation substantiated that the facility failed to notify resident representatives of significant changes, maintain a clean and safe environment, and prevent resident-to-resident abuse. Specific incidents included failure to notify representatives of hospitalizations for Residents #7 and #8, unsanitary conditions observed on multiple floors, and physical altercations 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 prevent physical abuse among residents. Several incidents of resident-to-resident physical abuse were substantiated, involving three residents.
Deficiencies (3)
F 0580: The facility failed to notify the resident's representative of significant changes in condition for two residents and failed to update representative contact information or make multiple contact attempts.
F 0584: The facility failed to provide a safe, clean, sanitary, and homelike environment in three of four hallways, including unclean resident rooms, stained linens and curtains, dirty dining and common areas, and presence of institutional odors.
F 0600: The facility failed to protect three residents from physical abuse by other residents, substantiating multiple incidents of resident-to-resident physical abuse.
Report Facts
Residents reviewed: 12
Residents affected: 2
Residents affected: 3
BIMS score: 15
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in failure to notify resident representative finding |
| NHA | Nursing Home Administrator | Interviewed regarding notification failures and facility policies |
| SSD | Social Services Director | Interviewed regarding notification procedures and abuse investigations |
| RNC | Regional Nurse Consultant | Interviewed regarding notification procedures |
| LPN #2 | Licensed Practical Nurse | Witnessed and intervened in resident-to-resident physical abuse incident |
| RN #1 | Registered Nurse | Assessed residents after physical abuse incidents |
| CNA #2 | Certified Nurse Aide | Witnessed and intervened in resident-to-resident physical abuse incident |
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident behavior and interventions |
| DON | Director of Nursing | Interviewed regarding abuse prevention and resident monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding 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 substantiated multiple issues including failure to maintain a clean environment, failure to prevent resident abuse (sexual and physical) by Resident #13 against multiple residents, and failure to protect a resident from financial exploitation by a staff member. The facility's investigation and monitoring were inadequate, and staff were not fully aware of resident behaviors or incidents.
Findings
The facility failed to maintain a clean and odor-free environment, failed to prevent multiple incidents of resident-to-resident abuse including sexual and physical abuse by Resident #13, and failed to protect Resident #7 from financial exploitation by a staff member. The facility also lacked timely and adequate investigation and monitoring of aggressive behaviors.
Deficiencies (3)
F 0584: The facility failed to maintain a safe, clean, sanitary, and odor-free environment in resident rooms and common areas, including soiled floors, stained linens, and offensive odors throughout the building.
F 0600: The facility failed to prevent sexual and physical abuse by Resident #13 against Residents #12, #14, and #23, and failed to implement timely care plan interventions despite known history of violent aggression.
F 0602: The facility failed to protect Resident #7 from financial exploitation when a housekeeper accepted $5,060 from the resident through direct bank transfers.
Report Facts
Residents reviewed for abuse: 23
Residents affected by abuse: 3
Amount of money taken: 5060
Number of bank transfers: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK #1 | Housekeeper | Responsible for cleaning second floor, interviewed regarding cleaning deficiencies |
| HK #2 | Housekeeper | Accepted $5,060 from Resident #7, terminated after investigation |
| John Smith | Director of Nursing | Interviewed regarding facility responses and monitoring of resident behaviors |
| NHA | Nursing Home Administrator | Conducted investigation into financial exploitation and abuse incidents |
| CNC | Corporate Nurse Consultant | Provided facility policies and interviewed regarding abuse and investigation |
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: 1
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 rooms showing evidence of soiled bedding, strong odors, mouse droppings, and unsanitary conditions. Pest control efforts were ongoing, but housekeeping practices were insufficient to remove rodent contamination and maintain cleanliness.
Deficiencies (1)
F 0584: The facility failed to ensure residents experienced a clean and sanitary homelike environment with living spaces free from odors, dirt, debris, and soiled areas. Mouse droppings were present and surfaces were not properly sanitized from possible rodent contamination.
Report Facts
Pest control visits: 6
Resident interviews: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Interviewed about 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: 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
Complaint Investigation
Deficiencies: 4
Date: Feb 14, 2024
Visit Reason
The inspection was conducted due to complaints regarding medication errors, sanitation, infection control, and environmental safety at the nursing home.
Complaint Details
The investigation was complaint-driven, focusing on medication errors, sanitation issues including pest control and garbage disposal, infection prevention and control failures, and environmental safety concerns. The complaints were substantiated with multiple findings.
Findings
The facility failed to maintain medication error rates below 5%, had sanitation and pest control issues including open dumpster lids and rodent presence, failed to maintain an effective infection prevention and control program, and did not provide a safe, clean, and comfortable environment for residents and staff.
Deficiencies (4)
F0759: The facility failed to ensure medication error rates were less than 5%, with a medication error rate of 17.24%. Errors included incorrect dosages, failure to administer ordered medications, and failure to notify physicians of missed doses.
F0814: The facility failed to ensure garbage and refuse were properly disposed of and dumpster lids were closed, resulting in trash and rodent harborage around dumpsters.
F0880: The facility failed to maintain an infection control program by not cleaning high-touch areas properly, not using proper disinfectant times, failing to perform hand hygiene, not providing hand hygiene to residents before meals, having empty hand sanitizer dispensers, and transporting resident laundry uncovered.
F0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment, with debris and food in resident rooms, hallways, and dining areas, open dumpsters with trash and rodents, kitchen contamination with mice droppings, 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error findings for incorrect medication administration and failure to notify physician. |
| LPN #3 | Licensed Practical Nurse | Named in medication error findings for administering incorrect medication and dosage. |
| 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 changes and infection control. |
| Maintenance Director | Maintenance Director | Interviewed regarding dumpster area cleanliness and housekeeping supervision. |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding dumpster area sanitation and staff education. |
| Housekeeping Manager | Housekeeping/Laundry/Maintenance Manager (HLM) | Interviewed regarding housekeeping procedures and infection control. |
| Social Services Assistant | Social Services Assistant (SSA) | Interviewed regarding resident room cleanliness complaints. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding facility sanitation, housekeeping staffing, and training. |
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 and investigations related to resident abuse, bed hold notification failures, dialysis care communication issues, medication errors, food safety and sanitation concerns, infection control deficiencies, and environmental safety issues at Wellsprings Care Center.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident physical abuse involving Resident #49 and other residents (#27, #39, #212, #6). Additional complaints included failure to provide bed hold notification, dialysis communication failures, medication errors, food safety and sanitation issues, infection control deficiencies, and environmental safety concerns.
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 administration errors, improper medication storage and labeling, unsanitary food preparation and storage conditions, inadequate pest control and garbage disposal, failure to maintain infection control practices including hand hygiene and cleaning of high-touch surfaces, and unsafe and unsanitary environmental conditions throughout the facility.
Deficiencies (9)
Failed to ensure residents were kept free from physical abuse by another resident.
Failed to provide appropriate bed hold notification for resident transferred to hospital.
Failed to communicate dialysis session information properly with dialysis center.
Medication error rate of 17.24% with errors including incorrect doses and failure to notify physician of missed medications.
Medications and biologicals were not properly labeled or stored; insulin pens lacked resident names and open dates; medications left unattended on carts; medication carts unclean.
Food safety violations including staff not wearing hair restraints, freezer not maintaining proper temperature, dry goods stored unsealed with rodent contamination, improper hand hygiene and glove use during food prep, and undated food in nourishment refrigerators.
Garbage and refuse improperly disposed of; dumpster lids left open; trash and food debris around dumpsters attracting rodents.
Infection control program failures including inadequate cleaning of high-touch surfaces, improper disinfectant contact times, housekeeping staff not performing hand hygiene, empty hand sanitizer dispensers, failure to offer hand hygiene to residents before meals, and uncovered resident laundry during transport.
Facility environment unsafe and unsanitary with debris and food in resident rooms, hallways, dining rooms, elevator; dumpsters overflowing and open; kitchen with mice droppings and improperly stored dry goods; cigarette butts at entrance.
Report Facts
Medication error rate: 17.24
Dialysis communication incomplete forms: 13
Residents affected by abuse: 4
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 of missed medications. |
| LPN #3 | Licensed Practical Nurse | Administered incorrect Methadone dose and medication substitution without proper order verification. |
| CK #1 | Cook | Observed not wearing beard net while preparing food. |
| CK #2 | Cook | Observed not wearing beard net while preparing food. |
| DM | Dietary Manager | Interviewed regarding food safety, sanitation, and dumpster area cleanliness. |
| HSK #1 | Housekeeper | Observed failing to perform hand hygiene and clean high-touch surfaces properly. |
| HSK #2 | Housekeeper | Observed failing to clean high-touch surfaces and perform hand hygiene between tasks. |
| NHA | Nursing Home Administrator | Provided facility policies and interviewed regarding multiple deficiencies and corrective actions. |
| MTD | Maintenance Director / Housekeeping Supervisor | Interviewed regarding housekeeping responsibilities and environmental cleanliness. |
| 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 medication administration practices. |
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 |
Inspection Report
Annual Inspection
Deficiencies: 3
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 abuse allegations and kitchen sanitation.
Findings
The facility failed to timely report an allegation of staff-to-resident abuse within the required two-hour window and allowed the alleged perpetrator to return to work before completing an investigation. Additionally, the facility failed to maintain proper kitchen sanitation by operating a dish machine without proper sanitizer concentration and failed to maintain refrigerator and freezer temperature logs.
Deficiencies (3)
F 0609: The facility failed to report an allegation of staff-to-resident abuse to the state survey agency within two hours after the allegation was made for one resident.
F 0610: The facility failed to protect one resident from further potential abuse by allowing the alleged perpetrator to return to work before completing an investigation.
F 0812: The facility failed to maintain proper kitchen sanitation by using a low temperature dish machine without ensuring proper sanitizer concentration and failed to maintain refrigerator and freezer temperature logs.
Report Facts
Sanitizer concentration: 0
Sanitizer concentration logged: 100
Dish machine operation times: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Named in abuse allegation and related findings | |
| Registered Nurse (RN) #1 | Reported abuse allegation and sent CNA #1 home | |
| Director of Nursing (DON) | Involved in investigation and reporting of abuse allegation | |
| Social Services Director (SSD) | Responsible for abuse investigation interviews and reporting | |
| Dietary Aide (DA) #1 | Operated dish machine without proper sanitizer concentration | |
| Account Manager | Responsible for kitchen oversight and temperature log compliance | |
| District Manager | Provided education on dish machine sanitizer and temperature logs | |
| Administrator | Oversaw facility operations and abuse allegation reporting |
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