Inspection Reports for
Aviva at Fitzsimons

The complaint investigation found that Resident #1 was injured when CNA #2 propelled the resident's wheelchair without foot pedals, causing the resident's right foot to get caught on the carpet and resulting in a comminuted fracture of the right femur. The incident was substantiated with video evidence and staff interviews.

The facility failed to ensure proper wheelchair transport for Resident #1, resulting in a right femur fracture caused by the resident's foot being caught under the wheelchair without foot pedals. The facility conducted an investigation, suspended and terminated the responsible CNA, and implemented corrective education and monitoring.

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 investigation was complaint-related, focusing on failure to monitor Resident #3 and failure to notify the nurse practitioner of declining vital signs. The complaint was substantiated with findings of inadequate monitoring and documentation.

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 monitoring per nurse practitioner orders was not evident.

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 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, inaccurate staffing data submission, and inadequate infection prevention and control practices including housekeeping and PPE use during medication administration via feeding tube.

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 was substantiated based on grievances filed by Resident #32's representative and Resident #3, reporting call light wait times exceeding 10 minutes, sometimes up to 60 minutes. Staff interviews and call light records supported these findings.

The facility failed to ensure timely response to call lights for two residents, resulting in prolonged wait times up to 60 minutes. Staff interviews and call light records confirmed ongoing issues despite staff education and interventions.

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 found that four residents experienced delayed call light responses leading to urinary incontinence and emotional distress. The complaint was substantiated with evidence from resident interviews, call light logs, and staff interviews.

The facility failed to ensure timely response to residents' call lights, resulting in embarrassment and urinary incontinence for four residents. Staff interviews revealed that call lights were sometimes unanswered for extended periods despite an alert system, and documentation of call light audits was lacking.

The facility was found deficient in multiple areas including failure to promptly resolve resident grievances about long call light wait times, inadequate provision of meaningful activities for residents, failure to administer pain medication as prescribed, improper storage and labeling of biologicals, breach of resident confidentiality, incomplete medical record documentation, failure to maintain emergency equipment properly, and unsafe environmental conditions including foul odors, improper trash disposal, and trip hazards from unsecured electrical cords.

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 facility was found deficient in multiple areas including failure to resolve resident grievances timely, inadequate provision of meaningful activities, failure to provide appropriate treatment and care according to orders, medication management errors, failure to safeguard resident identifiable information, incomplete and inaccurate medical records, failure to maintain emergency equipment, and unsafe environmental conditions including trip hazards and foul odors.

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 allegations that the facility failed to provide timely medical records to a government adult protection agency, failed to provide adequate pressure ulcer care, failed to prevent accidents and falls, and failed to maintain infection control standards. The investigation substantiated these allegations with findings of delayed medical record provision, inadequate wound care and prevention, failure to respond to call lights leading to a resident fall with fracture, and improper infection control during wound care.

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, and failed to maintain infection control standards during wound care for one resident. Additionally, the facility failed to ensure registered nurse assessments were completed following falls for two residents.

The complaint investigation was triggered by Resident #19's grievance that a certified nurse aide (CNA #5) yelled at her, treated her disrespectfully, and the facility failed to file and resolve the grievance promptly. The investigation found the grievance was not initially filed, and follow-up actions were delayed.

The facility failed to honor a resident's right to file a grievance and promptly resolve it, failed to update care plans timely for residents, failed to administer medications according to physician orders, failed to provide a therapeutic diet as prescribed, and failed to maintain food safety standards including discarding expired foods and properly covering food.

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.