Wheatridge Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured adequate supervision was provided for one (#18) of five residents reviewed out of 32 sample residents. Resident #18, who was at risk for falls related to weakness, multiple sclerosis (an autoimmune disease that affects the central nervous system) and a history of falls, was admitted to the facility on [DATE] for a long-term care stay due to the progressive nature of her illness. Per the resident's care plan, she required total staff assistance for activities of daily living (ADL), including showers. Resident #18 experienced an unwitnessed fall on 4/16/25 when she was left unsupervised in the main shower room, resulting in a fracture of her right femur. [...]

Inspectors wroteBased on observations and interviews, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to maintain an onsite and/or at least part-time infection control preventionist to properly assess, develop, implement, monitor, and manage the infection prevention and control program.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#17, #51 and #7) of six residents were free from chemical restraints were receiving the least restrictive approach for their needs out of 32 sample residents. Specifically, the facility failed to: -Ensure Resident #17's behavior care plan had resident specific non-pharmacological care approaches; -Document consistent behaviors for Resident #17, Resident #51 and Resident #7 to justify the continued use of psychotropic medications; and, -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #51 and Resident #7's psychotropic medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure services met professional standards of practice for four (#41, #111, #261 and #264) of 13 residents out of 32 sample residents. Specifically, the facility failed to ensure medications were not left at residents' bedsides and nurses monitored residents when they took their medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the facility had a designated registered nurse (RN) acting as the director of nursing (DON). Specifically, the facility failed to have a designated RN as the facility's fulltime DON.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and in the dry storage area. Specifically, the facility failed to ensure: -The kitchen was clean and sanitary; -Food was labeled and stored correctly in the walk-in refrigerator, freezer and the dry storage area; and, -Staff wore hairnets in the main kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#51 and #18) of three residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 32 sample residents. Specifically, the facility failed to: -Identify Resident #51 had a history of suicide attempts and suicidal ideation in order to monitor for worsening signs and symptoms of depression or suicidal ideation; and, -Address identified psychosocial distress impacting a resident's level of functioning for Resident #18, who expressed fear of showers after a fall with major injury in the shower.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the medication error rate was not five percent (%) or greater. Specifically, the facility had a medication error rate of 24%, which was six errors out of 25 opportunities for error.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in two of three medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure insulin pens were labeled with an open date; and, -Ensure inhalers were stored in a sanitary manner and labeled with resident names.

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 the housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high-frequency touched surfaces; and, -Ensure housekeeping staff performed appropriate hand hygiene.

Inspectors wroteBased on observations and 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 develop a maintenance program to ensure environmental concerns in the kitchen, dish room and the dry storage room were identified and corrected in a timely manner.

Inspectors wroteBased on observations and interviews, the facility failed to dispose of garbage and refuse properly for one of one dumpsters. Specifically, the facility failed to contain garbage and refuse within the dumpster.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection in one out of three hallways. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Failure to clean glucometers in a sanitary manner; -Failure to wear gloves while obtaining a blood glucose and giving an injection; -Failure to maintain an intravenous (IV) antibiotic administration set in a sanitary manner; and, -Failure to maintain a catheter in a sanitary manner

Inspectors wroteBased on observations, record review and staff interviews the facility failed to provide services for two (#20 and #50) of three out of 29 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #20 and Resident #50's vital signs were monitored prior to the administration of a blood pressure medication.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#40) of five residents reviewed were provided with services or treatments to prevent the reduction in range of motion out of 29 sample residents. Specifically, the facility failed to ensure Resident #40 was provided with preventative measures for contracture of her right hand.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free from significant medications error for one (#14) of nine residents reviewed for medication error out of 29 sample residents. Specifically, the facility failed to ensure that Resident #14 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure two residents (#6 amd #42) were free from resident-to-resident abuse out of 31 sample residents. Specifically, the facility failed to implement person-centered interventions to protect Resident #6, Resident #42 and Resident #13, who were roommates of Resident #35. Cross-reference F744: for failure to provide adequate dementia management care.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure two (#4 and #30) residents reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 31 sample residents. Specifically, the facility failed to: -For Resident #4, accurately document skin assessments, investigate abrasions and trauma injuries, and ensure that dressings were applied to the wounds as ordered by a treating practitioner; and, -For Resident #30, administer medication in accordance with professional standards. Medications were left at the bedside, next to the resident.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one (#24) of two out of 31 sample residents who required respiratory care was provided such care and services consistent with professional standards of practice. Specifically the facility failed to ensure a physician's order was obtained for Resident #24's use of a CPAP (continuous positive airway pressure) machine to include the CPAP settings and cleaning procedures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#35) of four out of 31 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care to prevent resident-to-resident altercations involving Resident #35. Cross-reference F600: for failure to ensure residents were free from verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control. Specifically, the facility failed to have an individual with training in infection prevention and control (IPC) to provide onsite management of their COVID-19 prevention and response activities.