Meade District Hosp Ltcu Dba Lone Tree Retirement

In the surveyor’s words

From the most serious findings on record at Meade District Hosp Ltcu Dba Lone Tree Retirement, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 13, 2024

  The facility reported a census of 32 residents, with three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)2, who the facility identified as an elopement risk. On 05/25/24 R2 displayed an increase in his wandering/exit seeking behavior which included statements he was going to leave, and he attempted to push open the front. […]

• No harm, potential for more than minimal, widespreadF812Aug 21, 2025

  The facility reported a census of 33 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.Findings included:- Observation of the kitchen and food storage areas on 08/19/25 at 07:40 AM revealed the following areas of concern:Dry storage concerns:Four cases of soda cans and a 50-pound bag of sealed flour were stored on the floor.One unsealed bag of marshmallows.One bag of unsealed russet instant mashed potatoes.A large container of pinto beans that was not sealed with the lid all the way.Several bottles of spices with no date opened and no expiration date.Walk-In Cooler… […]

• No harm, potential for more than minimal, widespreadF814Aug 21, 2025

  The facility reported a census of 33 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. This placed facility residents at risk for insect or rodent infestation.Findings included:- During a tour of the kitchen on 08/19/25 at 07:40 AM, observation revealed three garbage cans with no lids on them. During an observation on 08/20/25 at 10:20 AM, the same three garbage cans were found with no lids in the kitchen. Certified Dietary Manager (CDM) BB reported that the garbage cans did have lids and pulled a lid out from behind a garbage can and placed it on the can next to the steamer counter. CDM BB reported that the garbage cans should be covered. […]

• No harm, potential for more than minimal, widespreadF882Aug 21, 2025

  The facility reported a census of 33 residents. Based on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP). This failure has the potential to affect all 33 residents.Findings included:- During an interview on 08/19/25 at 07:50 AM, Administrative Staff A revealed she was the facility IP, and Administrative Nurse D assisted with the task. […]

• No harm, potential for more than minimal, widespreadF812Aug 30, 2023

  The facility reported a census of 27 residents with one central kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility. Findings included: - On 08/28/23 at 10:32 AM during the initial tour of the kitchen, revealed the facility's dish washer was not in working order. Dietary staff were washing all the dishes with the three-sink method. Dietary staff CC was in the dish room washing the dishes. He reported the dish machine was broke down and replacement parts were on back order. Until then, the dishes were being washed manually and sanitized. The dishes were sanitized with chlorine after washing. […]