Inspection Reports for
Life Care Center of Westminster
7751 Zenobia Ct, Westminster, CO 80030, United States, CO, 80030
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 4
Date: May 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's medication error rate and ensure it was less than five percent as part of regulatory compliance.
Findings
The facility failed to ensure the medication error rate was below five percent, with an observed error rate of 13%, consisting of four medication errors out of 29 opportunities. Deficiencies included failure to administer prescribed medications and failure to notify physicians when medications were unavailable.
Deficiencies (4)
Medication error rate was 13%, exceeding the 5% threshold, with four errors out of 29 opportunities.
Failure to administer Vitamin A and cranberry tablets as ordered and failure to notify the physician.
Failure to administer amlodipine and failure to notify the physician promptly.
Medication administration error where Simethicone was given instead of sodium bicarbonate due to nurse mistake.
Report Facts
Medication error rate: 13
Medication errors: 4
Opportunities for error: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Administered medications and failed to locate and administer prescribed medications; did not notify physician |
| LPN #1 | Licensed Practical Nurse | Administered medications, made medication administration error, and notified physician of unavailable medication |
| Director of Nursing | Director of Nursing | Interviewed regarding medication availability and communication systems |
Inspection Report
Routine
Deficiencies: 10
Date: May 1, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, grievance resolution, medication management, pressure ulcer care, antibiotic stewardship, and staff training requirements.
Findings
The facility failed to consistently honor resident shower preferences, promptly resolve grievances, ensure appropriate psychotropic medication use and monitoring, administer medications as ordered, provide adequate pressure ulcer prevention and care, monitor antibiotic use with proper physician rationale, maintain medication error rates below 5%, and provide required annual abuse prevention training to staff.
Deficiencies (10)
Failed to honor resident shower preferences for two residents (#53 and #26), resulting in inconsistent shower provision.
Failed to ensure prompt action to resolve grievances from resident groups regarding staffing, call light response, and hot water issues.
Failed to promptly resolve Resident #28's grievance regarding care provided by CNA #3.
Failed to ensure three residents (#61, #15, #28) were free from unnecessary psychotropic medications and lacked appropriate monitoring and physician rationale.
Failed to administer medications per physician's orders for Resident #28 in April 2025 due to medication unavailability.
Failed to provide appropriate pressure ulcer care and prevention for Resident #41, resulting in a facility-acquired unstageable pressure injury to the left heel.
Failed to act upon pharmacist recommendations in a timely manner for Resident #15 regarding antipsychotic medication use without documented diagnosis and adequate indication.
Medication error rate was 13%, exceeding the acceptable threshold of 5%, including missed medications and administration errors.
Failed to develop and implement an antibiotic stewardship program ensuring physician rationale and monitoring for long-term antibiotic use for Residents #41 and #35.
Failed to provide annual abuse identification, prevention, and reporting training to five staff members including CNAs and nurses.
Report Facts
Medication error rate: 13
Resident showers received: 7
Resident showers missed: 2
Pressure ulcer size: 3
BIMS score: 15
BIMS score: 4
MDS depression score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Named in grievance and care concern for Resident #28 |
| LPN #2 | Licensed Practical Nurse, Unit Manager | Named in grievance and medication administration findings |
| RN #1 | Registered Nurse | Involved in wound care and medication monitoring |
| DON | Director of Nursing | Interviewed regarding multiple findings including staffing, medication, and training |
| NHA | Nursing Home Administrator | Interviewed regarding grievance resolution and staff training |
| PCP #1 | Primary Care Physician | Interviewed regarding medication and wound care |
| MD | Medical Director | Interviewed regarding antibiotic stewardship and psychotropic medication monitoring |
| WCP | Wound Care Physician | Interviewed regarding pressure ulcer care for Resident #41 |
Inspection Report
Deficiencies: 1
Date: Nov 13, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights, specifically focusing on whether residents' call lights were answered in a timely manner.
Findings
The facility failed to ensure residents' call lights were answered promptly, resulting in feelings of neglect among residents. Observations and interviews revealed multiple instances where call lights were ignored or delayed, despite staff presence including the nursing home administrator and director of nursing.
Deficiencies (1)
Failed to ensure residents' call lights were answered in a timely manner, violating residents' right to a dignified existence.
Report Facts
Residents affected: 2
Call light response time: 14
Call light wait time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding call light response expectations and observed walking past call lights without answering. |
| Director of Nursing | DON | Mentioned by residents as not responding to call lights; present at nurses station during call light observations. |
| CNA #1 | Certified Nurse Aide | Interviewed about staffing levels and call light response issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect of a resident during a transfer by an agency CNA who failed to use the required mechanical lift.
Complaint Details
The complaint was substantiated. The facility reported an allegation of neglect after an agency CNA transferred Resident #1 without using the mechanical lift as required, resulting in injury. The agency CNA was not allowed to return to the facility and was reported to the state board of nursing.
Findings
The facility failed to ensure that Resident #1 was transferred using the appropriate mechanical lift method, resulting in the resident sustaining an acute fracture of her left femur. The agency CNA transferred the resident by standing and pivoting her without the mechanical lift, contrary to the care plan and facility policy.
Deficiencies (1)
Failure to protect Resident #1 from neglect by not using the required mechanical lift during transfer, resulting in a fracture.
Report Facts
Residents affected: 1
Pain scale rating: 7
Fracture fragment size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Facility CNA who requested assistance and was involved in the transfer. |
| CNA #2 | Certified Nurse Aide and Staff Scheduler | Facility CNA responsible for scheduling staff and provided information about the agency CNA. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding the improper transfer and resulting injury. |
| Director of Nursing | Director of Nursing (DON) | Provided facility policies and interviewed about the incident and agency CNA involvement. |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal regulations related to resident rights, grievance resolution, discharge planning, restorative care, fall prevention, respiratory care, and medication management.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care discussions, inadequate response to resident council concerns, failure to promptly resolve resident grievances, incomplete discharge summaries, failure to ensure proper use of splints for contracture management, inadequate supervision to prevent falls, failure to provide appropriate respiratory care including oxygen administration, and improper medication storage and labeling practices.
Deficiencies (8)
Failure to promote resident dignity and respect during care discussions for Resident #33.
Failure to address and act promptly on resident council grievances and concerns, resulting in residents feeling unheard.
Failure to provide prompt efforts to resolve grievances related to CNA availability for Resident #33.
Failure to ensure discharge summaries included a recapitulation of stay and final status for Resident #75.
Failure to ensure Resident #6's right hand splint was applied as ordered for contracture management.
Failure to ensure adequate supervision to prevent choking incident for Resident #55 and failure to conduct thorough fall investigations and implement timely interventions for Resident #63.
Failure to provide respiratory care in accordance with orders for Resident #55 including oxygen administration and monitoring.
Failure to remove expired medications and properly label and monitor medication storage refrigerators.
Report Facts
Residents reviewed: 29
Residents affected by dignity deficiency: 1
Residents affected by resident council deficiency: 6
Residents affected by grievance deficiency: 1
Residents reviewed for discharge: 3
Residents reviewed for restorative services: 4
Residents reviewed for oxygen use: 4
Medication storage refrigerator temperature missing days: 4
Medication storage refrigerator temperature missing days: 4
Medication storage refrigerator temperature missing days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Named in grievance and dignity findings related to Resident #33 care |
| LPN #3 | Licensed Practical Nurse | Named in grievance and dignity findings related to Resident #33 care |
| Unit Manager | Unit Manager | Interviewed regarding Resident #33 care and grievance follow-up |
| NHA | Nursing Home Administrator | Interviewed regarding multiple deficiencies including grievance follow-up and medication storage |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, grievance, discharge summary, and medication storage |
| IP | Infection Preventionist Nurse | Assigned to investigate grievance for Resident #33 |
| RN #2 | Registered Nurse | Interviewed regarding medication cart deficiencies and oxygen administration |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication storage and refrigerator temperature monitoring |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication storage and refrigerator temperature monitoring |
| IDON | Interim Director of Nursing | Interviewed regarding oxygen administration and fall investigations |
Inspection Report
Routine
Deficiencies: 8
Date: May 12, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication administration, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (call light accessibility), failure to resolve resident grievances timely, improper oxygen administration, inadequate pain management, medication errors, unsafe food storage, improper COVID-19 testing procedures, and incomplete COVID-19 vaccination tracking and mitigation for staff.
Deficiencies (8)
Failure to ensure Resident #18's call light was within reach in their room.
Failure to provide prompt efforts to resolve resident grievances related to food and roommate television noise.
Failure to administer oxygen to Resident #39 according to physician orders (oxygen set at 3 lpm instead of 4 lpm).
Failure to provide timely pain management and develop a pain care plan for Resident #163.
Medication errors including incorrect transcription of Lorazepam order for Resident #58 and failure to hold insulin per physician orders for Resident #8.
Failure to ensure food was stored under safe and sanitary conditions; unlabeled and undated foods found in nourishment room refrigerators.
Failure to follow proper COVID-19 testing procedures including inadequate testing location, lack of disinfection between tests, and improper staff training.
Failure to maintain and monitor COVID-19 vaccination status for all staff and contractors and failure to enforce N95 mask use for unvaccinated staff.
Report Facts
Residents in sample: 32
Lorazepam doses administered: 14
Oxygen liters per minute ordered: 4
Oxygen liters per minute observed: 3
Pain medication delay: 72
Expired milk date: Mar 7, 2022
Food expiration days: 3
Unvaccinated staff count: 4
Positive COVID-19 staff cases: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Unvaccinated staff observed wearing only surgical mask, not N95 as required |
| CNA #7 | Certified Nurse Aide | Unvaccinated staff observed wearing only surgical mask, not N95 as required |
| DA #3 | Dietary Aide | Performed invalid COVID-19 rapid test and lacked proper training |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including oxygen administration, pain management, medication errors, and COVID-19 vaccination tracking |
| NHA | Nursing Home Administrator | Interviewed regarding COVID-19 outbreak, testing procedures, vaccination tracking, and mitigation policies |
| IP | Infection Preventionist | Interviewed regarding COVID-19 testing and vaccination record deficiencies |
| RD | Registered Dietitian | Interviewed regarding food storage and grievance handling |
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