Inspection Reports for Pearl Street Health and Rehabilitation Center
CO, 80113
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
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Money withdrawn: 1000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
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: 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
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
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 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
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 |
Viewing
Loading inspection reports...
