Wheatridge Care Center

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110... Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with NFPA 101, Life Safety Code Sections 21.2.9 and 7.9.3.1.1. .. Based on observation and staff interview during the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3.. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain smoke barriers in .. Based on observation and staff interviews, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. .. Based on observation during the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 101, Section 19.3.2.4 and NFPA 99. .. Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1 & NFPA 58, 5.4.2.2... Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1... Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12. .. Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25,5.3.1.1.1 and NFPA 101, 19.7.6, and 4.6.12... Based on record review and staff interview during the survey, the facility failed to maintain all corridors in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; Section 4.3.12... Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4. .. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics. ..

A recertification survey with Incident #39879 was completed on 6/10/25 to 6/12/25. Ten deficiencies were cited. An Emergency Preparedness survey was conducted from 6/10/25 to 6/12/25. No deficiencies were cited. Based 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 a.. Based 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 sani.. Based 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 .. Based 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 re.. Based 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.Findings include:I. Facility policy and procedureThe Medication Administration policy, date.. Based 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 autoim.. Based 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-pharmacologica.. Based 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:-..