Inspection Reports for
Life Care Center of Longmont

CO, 80501

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Deficiencies (last 4 years)

Deficiencies (over 4 years) 9 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

73% worse than Colorado average
Colorado average: 5.2 deficiencies/year

Deficiencies per year

20 15 10 5 0
2019
2022
2024
2025

Inspection Report

Deficiencies: 1 Date: Sep 2, 2025

Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding notification of residents' representatives following significant changes in resident condition, specifically after a resident fall incident.

Findings
The facility failed to notify the designated representative of Resident #3 in a timely manner after the resident fell, resulting in delayed family notification until the resident became unresponsive and was transferred to the hospital. Staff interviews revealed inconsistent notification practices despite policy requirements.

Deficiencies (1)
F 0580: The facility failed to immediately notify the resident's representative of a significant change in condition after Resident #3 fell. Notification to the resident's power of attorney occurred eight hours after the fall, delaying family awareness of the incident.
Report Facts
Residents affected: 1 Delay in notification: 8 Resident sample size: 4

Employees mentioned
NameTitleContext
Director of NursingProvided facility policy and interviewed regarding notification procedures
Licensed Practical Nurse (LPN) #1Interviewed about notification practices following resident falls
Registered Nurse (RN) #1Interviewed about notification practices and familiarity with Resident #3

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Sep 2, 2025

Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's designated representative of a significant change in the resident's condition following a fall.

Complaint Details
The complaint investigation found that the facility did not notify Resident #3's power of attorney (POA) immediately after the resident fell, notifying the POA only eight hours later when the resident was unresponsive and transferred to the hospital. The resident's representative expressed frustration and emotional distress over the delayed notification and lack of communication.
Findings
The facility failed to notify the designated representative for Resident #3 after the resident fell, resulting in delayed family notification until the resident became unresponsive and was transferred to the hospital. The resident subsequently died after being placed on hospice care.

Deficiencies (1)
Failure to notify the resident's representative of a significant change in the resident's condition after a fall.
Report Facts
Residents in sample: 4 Residents affected: 1 Time delay in notification: 8 BIMS score: 12 Resident age: Age of Resident #3 (redacted)

Inspection Report

Routine
Deficiencies: 3 Date: Sep 9, 2024

Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, grievance response, and provision of appropriate treatment and care at Life Care Center of Longmont.

Findings
The facility failed to maintain resident dignity by not timely emptying an external catheter canister, did not respond promptly to resident grievances about long call light wait times, and failed to arrange timely medical specialist appointments as ordered for one resident.

Deficiencies (3)
F 0550: The facility failed to ensure dignity was maintained for Resident #1 by not emptying urine from her external catheter canister in a timely manner.
F 0565: The facility failed to respond timely to Resident #1's grievances regarding long call light wait times and did not maintain a systematic approach to ongoing resident grievances.
F 0684: The facility failed to arrange medical appointments with a dermatologist, urologist, and infectious disease specialist as requested by Resident #1 and ordered by the physician in a timely manner.
Report Facts
Call light wait time: 48 BIMS score: 15

Employees mentioned
NameTitleContext
Registered Nurse (RN) #1Interviewed regarding catheter canister emptying practices.
Director of Nursing (DON)Interviewed regarding catheter canister emptying, grievance responses, and scheduling of specialist appointments.

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Sep 9, 2024

Visit Reason
The inspection was conducted in response to complaints regarding resident care, dignity, grievance handling, and failure to arrange timely medical specialist appointments for Resident #1.

Complaint Details
The investigation was complaint-driven based on grievances filed by Resident #1's representatives regarding catheter care, long call light wait times, and failure to arrange specialist appointments. The complaints were substantiated with findings of deficiencies.
Findings
The facility failed to maintain resident dignity by not emptying an external catheter canister timely, did not respond promptly to grievances about long call light wait times, and failed to arrange timely specialist medical appointments as ordered. These deficiencies affected one resident out of three reviewed and were associated with minimal harm or potential for harm.

Deficiencies (3)
Failed to ensure dignity was maintained for Resident #1 by emptying urine from her external catheter canister in a timely manner.
Failed to act promptly upon grievances concerning resident care and long call light wait times for Resident #1.
Failed to provide treatment and care according to orders by not arranging timely medical appointments with specialists for Resident #1.
Report Facts
Call light wait time: 48 BIMS score: 15 Date of survey completion: Sep 9, 2024

Employees mentioned
NameTitleContext
Registered Nurse #1Registered NurseInterviewed regarding catheter care and stated nurses emptied and rinsed the canister every morning.
Director of NursingDirector of Nursing (DON)Interviewed regarding catheter care, grievance responses, and scheduling of specialist appointments.

Inspection Report

Routine
Deficiencies: 6 Date: Jan 23, 2024

Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, safety, infection control, medication management, and emergency preparedness.

Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for oxygen therapy for several residents, inadequate pressure ulcer prevention and care, failure to investigate and prevent skin injuries of unknown origin, improper medication storage and security, lapses in infection prevention practices including hand hygiene and equipment disinfection, and failure to maintain emergency crash carts with current and functional equipment.

Deficiencies (6)
Failure to develop and implement a complete care plan including measurable objectives and timeframes for oxygen treatment and care for four residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, including delayed interventions and failure to update care plans.
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically failure to investigate skin discoloration and skin tear of unknown origin for one resident.
Failure to ensure medications were stored in locked compartments with controlled medications permanently affixed and medication carts locked when unattended.
Failure to maintain an infection prevention and control program including failure to provide residents opportunity for hand hygiene before meals, failure of staff to perform hand hygiene between tasks and in rooms with enhanced precautions, and failure to disinfect vital signs equipment between residents.
Failure to maintain emergency response carts with current, unexpired equipment and functional oxygen canisters.
Report Facts
Sample residents reviewed: 36 Residents affected: 4 Residents affected: 2 Residents affected: 1 Medication refrigerators: 3 Crash carts: 3

Employees mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding care planning, pressure ulcer care, medication storage, infection control, and crash cart maintenance
Registered Nurse #1Registered NurseInterviewed regarding medication refrigerator storage
Registered Nurse #2Registered NurseObserved leaving medication cart unlocked and interviewed
Registered Nurse #3Registered NurseObserved not sanitizing vitals machine between residents and interviewed
Certified Nurse Aide #3Certified Nurse AideInterviewed regarding investigation of skin injuries
Director of Social ServicesDirector of Social ServicesInterviewed regarding investigation of skin injuries
Licensed Practical Nurse #1Licensed Practical NurseInterviewed regarding skin injury investigations
Infection PreventionistInfection PreventionistInterviewed regarding infection control practices
Dietary ManagerDietary ManagerInterviewed regarding hand hygiene practices during meal delivery
Regional Registered DietitianRegional Registered DietitianInterviewed regarding hand hygiene practices during meal delivery

Inspection Report

Complaint Investigation
Deficiencies: 6 Date: Jan 23, 2024

Visit Reason
The inspection was conducted to investigate complaints related to care planning, pressure ulcer prevention and care, accident hazards, medication storage, infection control, and emergency equipment maintenance at the Life Care Center of Longmont.

Complaint Details
The complaint investigation focused on multiple areas including care planning deficiencies for oxygen therapy, pressure ulcer prevention and treatment failures, inadequate investigation of skin injuries, medication storage violations, infection control lapses, and emergency equipment maintenance issues.
Findings
The facility failed to develop comprehensive care plans for oxygen therapy for multiple residents, did not implement timely interventions to prevent pressure ulcers resulting in actual harm, failed to investigate and prevent skin injuries for a resident, improperly stored medications, failed to ensure proper hand hygiene and infection control practices, and did not maintain emergency crash carts with current and functional equipment.

Deficiencies (6)
F 0656: The facility failed to develop and implement a complete care plan with measurable objectives and timeframes for oxygen treatment for four residents.
F 0686: The facility failed to provide appropriate pressure ulcer care and timely interventions to prevent new ulcers, resulting in stage 3 pressure ulcers for two residents.
F 0689: The facility failed to investigate skin discoloration and a skin tear of unknown origin and identify hazards and risks for one resident.
F 0761: The facility failed to ensure controlled medications were stored in locked, permanently affixed compartments and medication carts were locked when unattended.
F 0880: The facility failed to maintain an infection control program by not ensuring residents were offered hand hygiene before meals, staff performed hand hygiene between tasks and in rooms with enhanced precautions, and vitals machines were disinfected between uses.
F 0908: The facility failed to maintain emergency response carts by allowing expired equipment and medications and missing oxygen canisters on crash carts.
Report Facts
Sample residents reviewed: 36 Residents affected by care plan deficiency: 4 Residents affected by pressure ulcer deficiency: 2 Residents affected by accident hazard deficiency: 1 Medication refrigerators inspected: 3 Crash carts inspected: 3

Employees mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding care planning, pressure ulcer prevention, medication storage, infection control, and crash cart maintenance
Registered Nurse #1Registered NurseInterviewed about medication refrigerator storage
Registered Nurse #2Registered NurseInterviewed about leaving medication cart unlocked
Certified Nurse Aide #3Certified Nurse AideInterviewed about reporting and investigating skin injuries
Director of Social ServicesDirector of Social ServicesInterviewed about investigation of resident injuries
Infection PreventionistInfection PreventionistInterviewed about hand hygiene and infection control practices
Registered Nurse #3Registered NurseObserved and interviewed regarding vitals machine sanitation
Licensed Practical Nurse #1Licensed Practical NurseInterviewed about skin injury investigations
Dietary ManagerDietary ManagerInterviewed about hand hygiene wipes on meal trays
Regional Registered DietitianRegional Registered DietitianInterviewed about hand hygiene wipes on meal trays

Inspection Report

Annual Inspection
Deficiencies: 4 Date: Sep 28, 2022

Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements for the nursing home facility.

Findings
The facility was found deficient in multiple areas including failure to involve a resident in care planning, failure to respect and protect resident's personal belongings, failure to timely report suspected abuse or injury, and failure to maintain proper infection control related to oxygen tubing storage.

Deficiencies (4)
F 0553: The facility failed to allow Resident #40 to participate in the development and implementation of their person-centered care plan.
F 0557: The facility failed to ensure Resident #40 retained the right to have personal belongings treated with respect, including improper disposal of personal items.
F 0609: The facility failed to timely report an injury of unknown origin for Resident #2 within the required timeframe following identification.
F 0880: The facility failed to ensure oxygen tubing and nasal cannula were stored in a sanitary manner when not in use for Resident #9.
Report Facts
Deficiencies cited: 4 BIMS score: 14 BIMS score: 3 BIMS score: 4 Oxygen order: 2

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: Sep 28, 2022

Visit Reason
The inspection was conducted based on complaints regarding resident rights to participate in care planning, respect for personal belongings, timely reporting of suspected abuse or injury, and infection prevention related to oxygen equipment storage.

Complaint Details
The visit was complaint-related, investigating allegations that Resident #40 was not included in care planning and had personal belongings discarded, Resident #2 had an injury of unknown origin not reported timely, and Resident #9's oxygen equipment was improperly stored, risking infection.
Findings
The facility was found deficient in allowing Resident #40 to participate in care planning, respecting Resident #40's personal belongings, timely reporting of an injury of unknown origin for Resident #2, and maintaining sanitary storage of oxygen tubing and nasal cannula for Resident #9. Deficiencies were noted through observations, interviews, and record reviews.

Deficiencies (4)
Failed to provide Resident #40 the right to participate in the development and implementation of the resident's care plan.
Failed to ensure Resident #40 retained the right to have personal belongings treated with respect; personal items were discarded without consent.
Failed to timely report an injury of unknown origin for Resident #2 within the required timeframe.
Failed to ensure oxygen tubing and nasal cannula were stored in a sanitary manner when not in use for Resident #9.
Report Facts
Deficiencies cited: 4 Resident BIMS scores: 14 Resident BIMS scores: 3 Resident BIMS scores: 4 Oxygen flow rate: 2

Employees mentioned
NameTitleContext
Licensed Practical Nurse #1Unit ManagerUnaware of bruising on Resident #2's arm and stated bruising should have been reported immediately.
Registered Nurse #3Documented Resident #2's skin assessment but failed to report bruising as injury of unknown origin.
Director of NursingDirector of NursingReported injury to State, stated expectations for timely reporting of injuries and proper oxygen tubing storage.
Social Services Assistant #1Social Services AssistantProvided information about Resident #40's care conference documentation and inventory sheet.
Social Services DirectorSocial Services DirectorDescribed care conference invitation and documentation process.
AdministratorAdministratorStated expectations for resident inclusion in care conferences and oxygen tubing storage.
Certified Nursing Assistant #1Certified Nursing AssistantDescribed proper infection control practices for oxygen tubing and nasal cannula storage.
Registered Nurse #2Registered NurseDescribed proper storage and replacement procedures for oxygen tubing and nasal cannula.

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: Sep 26, 2019

Visit Reason
The inspection was conducted based on complaints and concerns regarding treatment and care, respiratory care, medication regimen reviews, and psychotropic medication use for multiple residents.

Complaint Details
The investigation was complaint-driven, focusing on treatment and care deficiencies, respiratory care inadequacies, medication regimen review delays, and psychotropic medication overuse without proper documentation or physician rationale.
Findings
The facility failed to ensure appropriate treatment and care for residents using orthotic devices, failed to provide necessary respiratory care orders for CPAP therapy, failed to act timely on pharmacist medication recommendations, and failed to limit psychotropic medication use with proper documentation and rationale.

Deficiencies (4)
F684: The facility failed to obtain physician orders for orthotic devices for Residents #19 and #296, include the devices in care plans, monitor skin under devices, and provide ordered wound treatment for Resident #19.
F695: The facility failed to ensure treatment and care orders were in place for the use of CPAP therapy machines for Residents #55 and #296.
F756: The facility failed to act timely on pharmacist recommendations for medication regimen reviews for Residents #84, #118, and #36 regarding antipsychotic, allergy, and antianxiety medications.
F758: The facility failed to limit PRN psychotropic medication orders to 14 days or provide physician rationale for extended use for Residents #84, #60, #118, #36, and #9.
Report Facts
Sample residents reviewed: 43 Residents affected: 2 Residents affected: 2 Residents affected: 3 Residents affected: 5 Haldol gel administrations: 34 Clonazepam administrations: 23 Ativan administrations: 18 Ativan administrations: 36

Inspection Report

Routine
Deficiencies: 4 Date: Sep 26, 2019

Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication regimen reviews, respiratory care, and psychotropic medication use in the facility.

Findings
The facility failed to ensure appropriate treatment and care for residents using orthotic devices, failed to provide necessary respiratory care orders for CPAP therapy, did not act timely on pharmacist medication recommendations, and failed to limit psychotropic medication use with appropriate stop dates or physician rationale. Several residents were affected by these deficiencies.

Deficiencies (4)
Failure to obtain physician orders for orthotic devices and include them in care plans, monitor skin condition, and provide ordered wound treatment for residents #19 and #296.
Failure to ensure treatment and care orders were in place for the use of CPAP therapy machine for residents #55 and #296.
Failure to act upon pharmacist recommendations timely for residents #84, #118, and #36 regarding medication diagnoses, doses, and frequency.
Failure to implement gradual dose reductions and limit PRN psychotropic medication orders to 14 days or provide physician rationale for extended use for residents #84, #60, #118, #36, and #9.
Report Facts
Residents reviewed: 43 Haldol gel administrations: 34 Clonazepam administrations: 23 Ativan administrations: 18 PRN Ativan administrations: 36

Employees mentioned
NameTitleContext
LPN #2Unit ManagerInterviewed regarding CPAP therapy and monitoring for Resident #55
DONDirector of NursingInterviewed regarding orthotic device orders, CPAP therapy, medication recommendations, and psychotropic medication use
LPN #1Unit ManagerInterviewed regarding pharmacy recommendations and psychotropic medication use for Residents #84, #118, and #60
PSCPharmacy Services ConsultantInterviewed regarding pharmacist recommendations and medication regimen reviews

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