Lone Tree Post Acute: Narcotic Tracking Failures - CA
The ADON confirmed what they were seeing: the dates and times documented in one set of records did not line up with the other....
Latest reports, citations, and penalties from CMS data
The ADON confirmed what they were seeing: the dates and times documented in one set of records did not line up with the other....
The resident, identified in inspection records only as R1, was found on the floor in front of his wheelchair at 5:30 AM....
When an inspector sat down with the resident nearly two weeks later, on April 27, he was calm....
Getting in or out required numeric codes at multiple points....
The April 27 complaint inspection turned on a gap between what Berkley Post-Acute put on paper and what it carried out....
The resident, identified in inspection records only as Resident 2, was readmitted to Studebaker Healthcare Center with baseline confusion....
The inspection was a complaint investigation, meaning it was triggered by a specific concern raised about the facility, not a routine survey....
The inspection, conducted April 24, 2026, stemmed from a complaint....
He fell at the facility on March 26, 2026....
Federal inspectors arrived at the facility on April 28, 2026, following a complaint....
His cognition was rated severely impaired....
He had been prescribed fidaxomicin, taken by mouth twice a day for five days....
The inspection was conducted April 28, 2026, following a complaint....
Inspectors visiting Staunton Post Acute & Rehabilitation on April 28, 2026, documented that Resident 107 was observed actively smoking at 2:40 p.m....
The incident involved Resident 1, whose name was withheld in the inspection report....
The resident, identified in inspection records only as Resident 4, fell on January 11, 2026, at 1:05 in the afternoon....
He told an inspector he had waited anywhere from 30 minutes to two or three hours on other occasions....
He then pointed to the privacy curtain between his bed and his roommate's....
There was no way to confirm the checks happened, no way to confirm the right dose was given, no way to confirm anything at all....
The inspection, conducted April 27, 2026, was triggered by a complaint....