Lone Tree Post Acute

In the surveyor’s words

From the most serious findings on record at Lone Tree Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF919May 22, 2023

  Based on observation, interview, and record review, the facility failed to repair and maintain a functional resident call light system (the means of communication between residents and staff) in residents' rooms, bathrooms, and shower rooms for a period of four months. The facility had 14 of 26 sampled residents with identified malfunctioning call lights (Residents 4, 5, 6, 9, 8, 11, 13, 15, 1, 3, 14, 12, 10, and 7), an alternative interim call bell (commonly known as service/reception bell) system/ process was not utilized, and residents had no means of calling for assistance. […]

• Actual harm, isolatedF686Apr 15, 2021

  Based on observation, interview and record review, the facility failed to ensure one (Resident 24) of one sampled residents did not develop a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and provide the necessary assessment, treatment and services to promote healing of a pressure ulcer when: Resident 24 developed a pressure ulcer over the buttocks and sacrum (large triangular bone in the lower back) on 12/24/20 and was not assessed or treated until 1/1/21, which resulted in Resident 24 developing a pressure ulcer and later development into a stage 4 (a wound with full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed). […]

• No harm, potential for more than minimal, widespreadF836Apr 27, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF732Apr 10, 2025

  Based 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. Findings: During multiple observations on 4/7/25, and 4/8/25, there was no staffing data posted in facility's reception, nursing station and/or hallways area. During an interview and record review on 4/9/25 at 12:07 p.m., with the Staff Scheduler (SS 1), facility's Nursing Staff Sign in Binder was reviewed. The binder had a document titled the census and direct care services hours per patient day (DHPPD). […]

• No harm, potential for more than minimal, patternF605May 1, 2026

  Based 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.Findings:a. […]