Inspection Reports for
Aviva at Fitzsimons

The complaint investigation found that Resident #1 sustained a fracture due to improper wheelchair transport by CNA #2. The incident was substantiated with video evidence showing the resident's foot caught under the wheelchair. The facility conducted an investigation, suspended and terminated CNA #2, and implemented corrective education and monitoring.

The facility failed to ensure proper wheelchair transport for Resident #1, which caused a closed displaced comminuted fracture of the right femur. The investigation revealed that CNA #2 propelled the resident's wheelchair without foot pedals, causing the resident's foot to get caught and injured. The facility took corrective actions including suspension and termination of CNA #2, staff education, and ongoing monitoring.

The complaint investigation found that the facility failed to monitor Resident #3 as ordered and failed to notify the nurse practitioner of the resident's declining condition. The complaint was substantiated with findings of minimal harm or potential for actual harm affecting a few residents.

The facility failed to consistently monitor Resident #3 during a change in condition, did not follow physician's orders, and failed to notify the provider when the resident's blood pressure and heart rate dropped. Documentation was incomplete and nursing staff did not adequately monitor the resident as ordered.

The complaint investigation was substantiated with findings that residents experienced long call light wait times, sometimes up to 50-60 minutes, despite staff training and interventions. Grievances filed by Resident #32's representative and Resident #3 confirmed ongoing issues with call light response times.

The facility failed to ensure timely and dignified care by consistently answering call lights promptly for two residents out of four reviewed. Multiple grievances and interviews revealed prolonged call light activation times ranging from 15 to over 60 minutes, despite staff education and interventions. Staffing issues, equipment problems, and use of agency staff contributed to delays.

The facility was found deficient in multiple areas including failure to ensure timely response to call lights affecting resident dignity, incomplete annual performance reviews for nurse aides, medication errors exceeding 5%, improper food handling and storage practices, inaccurate staffing data submission, and inadequate infection prevention and control practices including housekeeping and PPE use during medication administration.

The complaint investigation found that four residents experienced delayed call light responses leading to urinary incontinence and emotional distress. Residents expressed frustration and embarrassment due to long wait times. Staff interviews confirmed expectations for call light response times and described the alert system. The director of nursing acknowledged issues with pager functionality and lack of documentation for call light audits.

The facility failed to ensure timely response to call lights for four residents (#240, #242, #245, and #246), resulting in episodes of urinary incontinence and resident frustration and embarrassment. Staff interviews revealed that call lights should be answered within 5 to 15 minutes, but call light logs showed multiple instances where call lights were on for extended periods, sometimes exceeding 30 minutes. The facility's call light alert system was described, and some pagers were found in disrepair, but no documentation of call light audits was provided.

The complaint investigation was substantiated with findings of deficiencies related to call light response times, activities programming, treatment and care, medication management, confidentiality breaches, medical record documentation, emergency equipment maintenance, and environmental safety.

The facility failed to promptly resolve resident grievances about call light response times, provide meaningful activities for residents, ensure appropriate treatment and care for residents with complex medical needs, manage pain medication correctly, maintain confidentiality of protected health information, keep accurate and complete medical records, maintain emergency equipment properly, and provide a safe, clean, and comfortable environment free of hazards.

The facility was found deficient in multiple areas including failure to promptly resolve resident grievances about long call light wait times; failure to provide meaningful and consistent activities for residents; failure to administer scheduled pain medication correctly; failure to discard expired vaccines; failure to safeguard resident-identifiable information; incomplete and inaccurate medical record documentation; failure to maintain emergency equipment properly; and failure to maintain a safe, clean, and comfortable environment including control of foul odors, proper trash disposal, and prevention of trip hazards from electrical cords.

The complaint investigation was triggered by allegations that the facility failed to provide timely medical records to a government adult protection agency for three residents, failed to provide appropriate pressure ulcer care, failed to prevent accidents including falls, and failed to maintain infection control standards. The investigation included interviews with agency staff, facility staff, residents, and review of medical records and policies.

The facility failed to provide timely medical records to a government agency for three residents, failed to provide appropriate pressure ulcer care and prevention for two residents, failed to ensure adequate supervision to prevent accidents for three residents including failure to respond timely to call lights leading to a fall with fracture, and failed to maintain infection control standards during wound care for one resident.

The complaint investigation was triggered by Resident #19's grievance that CNA #5 yelled at her and was disrespectful. The facility initially failed to file a grievance or respond appropriately but later filed a grievance and educated staff after the survey.

The facility failed to file a grievance on behalf of Resident #19 regarding a certified nurse aide's rude behavior, failed to promptly respond and follow up with the resident, and did not educate the staff appropriately before allowing the aide to continue working on the same hall. The facility later filed a grievance and educated the staff after the survey.