Lone Tree Health Care Center Inc

In the surveyor’s words

From the most serious findings on record at Lone Tree Health Care Center Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF609Nov 20, 2025

  Based on clinical record review, policy review and staff interview, the facility failed to report an allegation of potential financial exploitation to the State Agency for 1 of 14 residents reviewed (Resident #33). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #33 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognition impairment. The MDS further revealed the resident did not have behavioral symptoms and did not have any psychiatric/mood disorders. The Care Plan initiated 8/25/25 revealed Resident #33 had an activities of daily living (ADL) deficit and required assistance from staff with toileting and transferring. […]

• No harm, potential for more than minimal, isolatedF637Nov 20, 2025

  Based on clinical record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner following admission to hospice care for 1 of 2 residents reviewed (Resident #10). The facility reported a census of 33 residents. Findings include: The Clinical Census for Resident #10 revealed an admission date to hospice on 7/18/25. The MDS dated [DATE] for Resident #10 revealed it was a significant change assessment and the resident entered hospice care within the last 14 days. On 11/19/25 at 11:35 AM the Administrator confirmed a significant change MDS had not been completed within 14 days as she would have expected following Resident #10's admission to hospice care. […]

• No harm, potential for more than minimal, isolatedF693Apr 11, 2024

  Based on clinical record review, staff interviews, and facility policy review the facility failed to provide the tube feeding (TF) according to the physician's order individualized to the resident for 1 of 1 residents reviewed with tube feeding sampled (Resident #3). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #3 dated 10/20/23, listed diagnoses of malnutrition, anemia, and heart failure. The MDS identified Resident #3's Brief Interview for Mental Status (BIMS) score of 9 out of 15, moderate cognitive impairment. The MDS identified Resident #3 received a tube feeding. The Care Plan for Resident #3 dated 11/1/23, reflected Resident #3 required a tube feeding related to swallowing problems, stricture. […]

• No harm, potential for more than minimal, isolatedF656Jun 22, 2023

  Based on clinical record review,staff interviews, and facility policy review the facility failed to complete a Comprehensive Care Plan for 1 of 12 residents in the sample (Resident #3). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], listed diagnosis for Resident #3 included: Type 2 diabetes, fracture of left femur, and cardiac arrhythmia (irregular heart beat). The MDS assessed the two weeks prior the resident exhibited symptoms of feeling tired or having little energy, feeling bad about self/letting others down, and trouble concentrating on things 12-14 half or more of the days. […]

• No harm, potential for more than minimal, isolatedF657Jun 22, 2023

  Based on clinical record review, staff interview and facility policy review, the facility failed to revise/update the Comprehensive Care Plan after a resident experienced a significant change; and another resident had a fall for 1 of 12 residents (Resident #3). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], listed diagnosis for Resident #3 included: Type 2 diabetes, fracture of left femur, and cardiac arrhythmia (irregular heart beat). The MDS assessed the resident required extensive assistance of two staff for: bed mobility, dressing, and toilet use; and extensive assistance of one for dressing, and personal hygiene. The resident required total dependence for: transfers, and locomotion on unit and off the unit. […]