Lone Tree Post Acute

Inspectors wroteBased on interview, and record review, the facility failed to ensure non-pharmacological interventions (without the use of medication or drugs) were implemented and documented for 3 of 5 sampled residents (Resident 1, Resident 71, and Resident 106) reviewed for unnecessary medications when the facility administered psychotropic medications (mind altering drugs) to Resident 1, Resident 71, and Resident 106 without evidence of individualized non-pharmacological interventions to address the residents' behavioral symptoms, or mood-related concerns prior to or in conjunction with medication use. This failure had the potential to result in unnecessary psychotropic medication use, adverse side effects, excessive sedation (difficult to stay awake), and medication dependency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for 2 of 26 sampled residents (Resident 109, and Resident 4) when:Resident 109 did not have an order for the use of a Continuous Glucose Monitor (CGM - a device that continuously checks a person's blood sugar levels throughout the day and night without the need of a blood sample) and there was no facility policy to address the resident use of a CGM.A physician-ordered fluid restriction (limiting the amount of liquids a person can drink) was not implemented for Resident 4. [...]

Inspectors wroteBased on interview, and record review, the facility did not maintain acceptable parameters of nutritional status for 3 of 26 sampled Residents (Resident 1, Resident 86, and Resident 96) when:1. Resident 96's unplanned weight loss in March of 2026 was not addressed,2. Resident 96's monthly weight was not completed for January 2026,3. Resident 86's monthly weights were not completed from January 2026 through March 2026; and,4. Resident 1's monthly weights were not completed from March 2026 through April 2026. These failures placed Resident 1, Resident 86, and Resident 96 at risk of ongoing unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care (care and treatment provided to help a person breathe better) was provided in accordance with professional standards of practice for 3 of 26 sampled residents (Resident 4 and Resident 106) when:A physician-ordered Continuous Positive Airway Pressure (CPAP - a machine that helps a person breathe by gently blowing air through a mask while sleeping) therapy was not carried out. Resident 106's nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen directly into a patient's nostrils) was not labeled/dated to identify when the equipment was last changed. Physician orders for supplemental oxygen (extra oxygen given to help a person breathe and maintain healthy oxygen levels) and head of bed orders for Resident 71 were not followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 94 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 4 errors out of 27 opportunities which resulted in a facility wide medication error rate of 14.81% in three out of six residents (Resident 68, Resident 40, Resident 28) during medication administration observation when:Resident 68 omeprazole (a medication used to protect the stomach lining), 10 mg (mg-milligram a unit or measurement) Delayed Release Oral Capsule was not given as ordered by the doctor; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and serve food per food safety standards when:The reach-in refrigerator in the dry storage area of the kitchen had missing entries on the temperature log. The reach-in refrigerator in the dry storage area of the kitchen had several strawberries with mold. A vent in the dry storage area of the kitchen had dust. Two vents in the food prep area were dusty and with rust. The ceiling above the tray line was cracked approximately three feet in length. These failures had the potential to lead to cross contamination and food borne illness for the 94 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for 1 of 26 sampled residents (Resident 32), when Resident 32's Foley catheter (a thin, flexible tube used to drain urine from the bladder) drainage bag was left uncovered and visible. This failure did not promote a dignified environment and had the potential to compromise Resident 32's privacy, autonomy, and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for 2 of 26 sampled residents (Resident 108 and Resident 54). This failure limited Resident 108 and Resident 54's ability to request assistance and had the potential risk for unmet needs, falls, and injury.

Inspectors wroteBased on interview, and record review, the facility failed to notify the physician of a change of condition for 1 of 26 sampled residents (Resident 96), when Resident 96 experienced an unplanned weight loss in March 2026. This failure resulted in a delayed physician response and delayed interventions to address Resident 96's change of condition. This failure also had the potential to impact Resident 96's health.

Inspectors wroteBased on interview and record review, the facility failed to submit a new Level I Preadmission Screening and Resident Review (PASRR- a screening for mental illness and treatment to ensure the facility coordinates with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services appropriate to their needs) for 1 of 26 sampled residents (Resident 12), when a level I PASRR was not completed for Resident 12. This failure had the potential to result in unmet specialized service needs for Resident 12 and the lack of appropriate evaluation and care plan interventions.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive care plan for 2 of 26 sampled residents (Resident 83 and Resident 96), when:1. Resident 83 did not have a care plan to address her chronic pain (pain that lasts longer than the standard healing time, usually greater than 6-months); and,2. Resident 96 did not have a care plan to address his weight loss. These failures had the potential for Resident 83 and Resident 96's needs to not be met and a delay in implementing interventions. Resident 83 was at risk for increased pain and discomfort and Resident 96 was at risk for ongoing weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer prevention interventions were implemented in accordance with professional standards of practice for 2 of 15 sampled residents (Resident 26 and Resident 3) when Low Air Loss (LAL - a special mattress that helps prevent and treat bed sores by blowing gentle air through the mattress) mattresses were in use without a physician's order. This failure placed Resident 26 and Resident 3 at risk for ineffective pressure redistribution, development of pressure injuries, or worsening of existing skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accidents and hazards for 1 of 26 sampled residents (Resident 62) when Resident 62 was found carrying a cigarette lighter without staff supervision. This failure had the potential for burn related injuries due to the risk associated with Resident 62 carrying a lighter (ignition and combustion of materials).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate pain management was provided to one of twenty-six sampled residents (Resident 83) when Resident 83's pain was not assessed appropriately by staff and non-pharmacological pain interventions (interventions that do not involve the use of medications to treat pain) were not implemented for Resident 83These failures resulted in unmanaged, increased pain, and hindered Resident 83's participation in rehabilitation services and recovery.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staff and supervised by a qualified social worker which affected all 98 residents. This failure resulted in all residents receiving social services care from unqualified staff. During an interview on 4/9/26, at 1:24 p.m., with the Social Services Director (SSD), SSD stated they were the primary staff responsible for the social services department. SSD stated they had bachelor's degree in engineering. During a concurrent interview and record review on 4/10/26, at 9:40 a.m., with Human Resources (HR), SSD's two job descriptions both titled, Job Description: Social Services Director, dated 3/2017 and 2/2024 was reviewed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents (1-8), the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to post direct care daily staffing data on a daily basis. This failure resulted in nurse staffing data not being posted in a visible and prominent place where it was accessible to residents and visitors.

Inspectors wroteBased on observations, interviews, and record reviews, facility failed to ensure one of four sampled residents (Resident 83) received a combination tablet of Calcium and Vitamin D per physician's order and Fluticasone nasal spray per manufacturer's recommendation. 1. Licensed Vocational Nurse (LVN) 1 administered 600mg+400 units of Calcium + Vitamin D instead of 600mg +200 units of Calcium + vitamin D. 2. LVN 1 did not shake and/or prime (remove the air from the applicator/nasal piece and fill the applicator/nasal piece with medication) prior to administering the nasal spray. Facility's medication error rate was 6.6.%. This failure resulted in Resident 83 not receiving Calcium/ Vitamin D supplement per physician's orders and placed Resident 83 at risk of not receiving the correct dose and concentration of the nasal spray.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure one of one medication storage room, had unexpired resident care and treatment supplies. Expired items including two wound swab tubes, six blood test tubes, three syringes, and two covid test kits, five packs of Intravenous Antibiotics (IV ATB- medication used to treat infections, given directly into the veins) medication for a discharged resident, were kept with ready to use supplies. This failure placed facility's residents at risk for getting exposed to expired treatment supplies, inaccurate lab test results.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prepare, distribute, serve food in a safe, clean, and sanitary manner for 97 out of 97 residents, not following professional standards for food service safety and not following their facility policy and procedures, when: 1. staff failed to wear hair covering in the food preparation (the series of operational processes involved in prepping foods for serving, such as: washing, mixing ingredients, cutting, slicing, washing etc ) area. 2. Kitchen staff failed to use and maintain cutting board in a good condition to chop up and prepare food for the residents. 3. Facility did not maintain the kitchen ceiling in good, repaired condition. 4. Facility failed to maintain ceiling vent above tray line area in a clean condition, free from dust and other air particles. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper standard precautions to prevent the spread of infection when: 1. Laundry Staff 1 stored her personal clothing item in the clean linen/laundry area. 2. Licensed Nurse brought original packaging of Resident 73's inhaler and Resident 83's nasal drops into the residents' respective rooms and then stored the packaging back to the medication cart. These deficient practices created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in spread of infection to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' privacy and dignity rights were respected for two of two sampled residents (Resident 49 and Resident 56). Resident 49 and 56 did not have privacy during activities of daily living (ADL) care. This failure resulted in not providing privacy for Resident 49 and Resident 56, and Resident 49 feeling neglected.

Inspectors wroteBased on observation, interview and record review, the facility falied to provide a written notice with reason for room change to one of one sampled resident (Resident 14)/ resident representative prior to changing Resident 14's room. This failure had the potential for Resident 14 to experience emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-an assessment and care screening tool used to guide care), was accurate for one of one sampled resident (Resident 146) when Resident 146's admission MDS was not coded accurately to reflect resident's use of continuous oxygen (O2) therapy. This deficient practice resulted in an inaccurate reflection of Resident 146's admission assessment and had the potential for resident to not receive appropriate care and treatment necessary to meet the needs for her identified conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oral and fingernail care to one of one sampled Resident when Resident 23 had dry mouth, and black matter under fingernails. This failure resulted in compromised daily care and appearance for Resident 23; and placed her at risk for compromised dignity and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide foot care to two of three sampled residents, (Resident 34 and Resident 35). Facility did not provide podiatry services (the treatment of the feet and their ailments) to address their long, and thick toenails. This failure resulted in Resident 34 feeling uncomfortable while wearing shoes and walking for too long and Resident 35 being in pain due to thick toenails.

Inspectors wroteBased on observation, interview, and record review, for one of one sampled resident (Resident 146), the facility failed to ensure appropriate oxygen (O2) therapy was administered when resident received continuous O2 at a flow rate of three liters per minute (3 LPM) instead of two (2) LPM, as ordered by the physician. This deficient practice to administer excessive O2 administration on a chronic obstructive pulmonary disease (COPD, a lung condition caused by damage to the airways and other parts of the lungs) patient has placed Resident 146 at risk for compromised breathing which may lead to further adverse effects.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure the baseline care plan included the primary diagnosis and related respiratory treatments for 1 (Resident #267) of 19 sampled residents.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to have a medication error rate less than 5%. The facility had 2 medications errors out of 27 opportunities, which yielded a medication error rate of 7.41% for 2 (Resident #8 and Resident #52) of 6 residents observed for medication administration.