Aviva at Fitzsimons

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident's provider when there was a significant change in the resident's condition for one (#4) of four residents out of 12 sample residents. Specifically, the facility failed to notify the resident's provider for Resident #4 when he had a change in blood pressure from his baseline.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 10 sample residents remained free from accidents. Resident #1 was admitted to the facility on [DATE] with diagnoses of history of falling, a fracture of the left ilium (upper part of the pelvis), atrial fibrillation (AFIB), hypertension (high blood pressure) and dementia. Resident #1 had severe cognitive impairments and required maximum assistance from staff. On 8/13/25 at approximately 4:30 p.m. Resident #1 was seated at the nurses' station where he sustained an unwitnessed fall. Resident #1 was assessed by a registered nurse (RN) and was assessed to have no injuries. After the fall, the staff assisted Resident #1 in his wheelchair back to the nurses' station. Certified nurse aide (CNA) #2 assisted Resident #1 to his room. [...]

Inspectors wroteBased on record review and interviews the facility failed to provide services for one (#3) of three residents out of seven sample residents according to professional standards of practice. Specifically, the facility failed to: -Ensure Resident #3 was consistently monitored when having a change in condition; -Follow the physician's orders; and, -Call the provider when Resident #3's blood pressure and heart rate dropped.

Inspectors wroteBased on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review ofevery nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of five certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5 in order to determine potential training needs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents' rooms; -Ensure housekeeping staff performed appropriate hand hygiene and changed gloves after cleaning residents' toilets; [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for two residents (#32 and #3) out of four residents reviewed for dignity of 26 sample residents. Specifically, the facility failed to provide Resident #32 and Resident #3 with a dignified existence by ensuring call lights were consistently answered in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.06%, or two errors out of 33 opportunities for error.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on one of two units. Specifically the facility failed to ensure safe and appropriate storage of food items in personal resident refrigerators.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#240, #242, #245 and #246) of five residents out of 11 sample residents. Specifically, the facility failed to ensure Resident #240, Resident #242, Resident #245 and Resident #246 experienced a dignified living experience by answering the residents' call lights in a timely manner. Resident #240 and Resident #242, who required assistance with toileting, expressed embarrassment, frustration and anger due to long call times and not being provided timely assistance which resulted in them experiencing episodes of urinary incontinence.

Inspectors wroteBased on record review and interviews, the facility failed to keep confidential resident-identifiable personal information and medical treatments for 27 of 27 residents; and to ensure medical records were complete and accurately documented medical status and response to nursing/medical care and treatment in keeping with accepted standards of practice for a sample of two of four residents reviewed. Specifically, the facility failed to: -Keep confidential information specifically protected health information (PHI) out of view of other residents and visitors for 27 of 27 residents on the unit; and, -Ensure Resident #47's medical record contained accurate and complete documentation regarding the resident's restorative management plan; restorative services provided; and the resident's response to services.

Inspectors wroteBased on observations and interviews, the facility failed to maintain emergency patient care equipment in safe operating condition. Specifically, the facility failed to perform daily quality readiness checks on the emergency response cart and to ensure expired items were removed and replaced.

Inspectors wroteBased on interviews and record review, the facility failed to provide prompt acceptable resolution to resident/resident representative grievances that were important to the residents. Specifically, the facility failed to resolve grievances for long call wait times in a manner that was satisfactory to the residents in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure meaningful activities designed to support residents physical, mental, and psychosocial well-being were provided for three (#1, #4 and #41) of six residents out of 52 sample residents. Specifically, the facility failed to: -Offer the resident population a consistent and regular scheduled activities program that included both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community; -To provide residents #1, #4 and #41 meaningful activities; and, -To offer residents #1, #4 and #41 regularly scheduled activities of choice.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public in one of three units. Specifically, the facility failed to: -Control foul odors throughout the two-south unit; -To properly dispose of trash soiled with feces and urine; -To maintain cleanliness in the dirty utility room; and, -To keep electrical cords out of walkways, in resident rooms in order to prevent trip hazards.

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one (#52) out of 52 sample residents. Specifically, the facility failed to administer scheduled pain medication, for neuropathy pain, at the correct dosage as ordered by the resident's physician, to Resident #52.

Inspectors wroteBased on observations and interviews, the facility failed to ensure biologicals were labeled and stored in accordance with accepted professional standards for one of four medication storage rooms. Specifically, the facility failed to discard expired vaccines from the medication storage room.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Ensure expired foods were discarded from two of three nutrition refrigerators; and -Ensure an uncovered pie was discarded from the walk in freezer.

Inspectors wroteBased on interview and record review the facility failed to address a resident's concern to their satisfaction for one (#19) of one resident reviewed for grievances out of 20 sampled residents. Specifically, the facility failed to: -Honor Resident #19's right to have a grievance filed on her behalf when she reported a concern regarding certified nurse aide (CNA) #5; -Promptly respond, verbally and in writing, Resident #19's reported concern; -Follow up with Resident #19 and provide resolution to her concern; and -Educate CNA #5 and provide resolution to Resident #19 before CNA #5 continued to work on the same hall where Resident #19 resided.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the accuracy and timely revision of care plans for two (#17 and #37) of three care plans reviewed out of 20 sample residents. Specifically, the facility failed to ensure: -Resident #17's care plan reflected her current transfer status; and -Resident #37's care plan included his current therapeutic diet.

Inspectors wroteBased on record review, and interview, the facility failed to ensure services provided met professional standards for medication administration. Specifically, the facility failed to: -Administer Prevacid (proton pump inhibitor) according to physician orders for Resident #27; -Administer Acyclovir (antiviral) according to physician orders for Resident #145; and -Ensure the medications were available and administered according to physician orders for Resident #17.

Inspectors wroteBased on record review and interviews, the facility failed to provide a therapeutic diet as prescribed by the physician to one (#37) out of two sampled residents for therapeutic diet, out of a total sample of 20 residents. Specifically, the facility failed to consistently provide Resident #37 with a diet that met the physician ordered therapeutic diet of neutropenic (all foods cooked).