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)
10 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
92% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 10
Date: May 1, 2025
Visit Reason
Routine inspection of Life Care Center of Westminster to assess compliance with regulatory requirements including resident rights, medication management, pressure ulcer care, antibiotic stewardship, and staff training.
Findings
The facility failed to consistently honor resident shower preferences, adequately resolve grievances, properly monitor psychotropic medication use, administer medications as ordered, prevent pressure ulcers, monitor long-term antibiotic use, ensure medication error rates below 5%, and provide annual abuse prevention training to staff.
Deficiencies (10)
F 0561: The facility failed to honor resident shower preferences for Residents #53 and #26, resulting in inconsistent shower provision contrary to their care plans.
F 0565: The facility failed to promptly resolve grievances from residents regarding staffing shortages, call light response times, and lack of hot water for showers.
F 0585: The facility failed to provide prompt efforts to resolve Resident #28's grievance regarding care by CNA #3, despite multiple reports and documented concerns.
F 0605: The facility failed to ensure Residents #15, #28, and #61 were free from unnecessary psychotropic medications due to lack of appropriate monitoring, diagnosis documentation, and physician rationale.
F 0684: The facility failed to administer multiple medications to Resident #28 as ordered in April 2025 due to medication unavailability and lack of physician notification.
F 0686: The facility failed to prevent a facility-acquired unstageable pressure ulcer on Resident #41's left heel due to lack of timely offloading and heel protection interventions.
F 0756: The facility failed to ensure timely physician review and action on pharmacist recommendations for Resident #15's antipsychotic medication regimen.
F 0759: The facility's medication error rate was 13%, exceeding the acceptable rate of less than 5%, including failure to administer medications and medication administration errors.
F 0881: The facility failed to develop and implement an effective antibiotic stewardship program including lack of physician rationale and monitoring for long-term antibiotic use for Residents #41 and #35.
F 0943: The facility failed to provide annual abuse identification, prevention, and reporting training to five staff members including CNAs and nurses within the past 12 months.
Report Facts
Medication error rate: 13
Resident sample size: 33
Shower opportunities for Resident #53: 11
Pressure ulcer size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in grievance and shower care findings |
| CNA #2 | Certified Nurse Aide | Named in shower care findings and grievance interviews |
| CNA #3 | Certified Nurse Aide | Named in grievance and shower care findings |
| RN #1 | Registered Nurse | Named in medication and abuse training findings |
| LPN #1 | Licensed Practical Nurse | Named in medication and abuse training findings |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including medication management, antibiotic stewardship, and abuse training |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding multiple findings including grievance resolution and abuse training |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding medication monitoring and antibiotic stewardship |
| Medical Director | Medical Director | Interviewed regarding psychotropic medication and antibiotic stewardship |
| Primary Care Physician #1 | Primary Care Physician | Interviewed regarding psychotropic medication and antibiotic stewardship |
| Wound Care Physician | Wound Care Physician | Interviewed regarding pressure ulcer care for Resident #41 |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration standards and to ensure the medication error rate was below 5 percent.
Findings
The facility failed to ensure the medication error rate was less than five percent, with a reported error rate of 13%, consisting of four errors out of 29 opportunities. Medication administration errors involved failure to administer prescribed medications and failure to notify physicians when medications were unavailable.
Deficiencies (3)
F0759: The facility failed to ensure medication error rates were less than 5 percent. The medication error rate was 13%, with four errors out of 29 opportunities for error.
Licensed practical nurse (LPN) #3 did not administer Vitamin A and cranberry tablets as ordered because the medications were not located and did not notify the physician.
LPN #1 did not administer amlodipine as ordered because it was not available and mistakenly administered Simethicone instead of sodium bicarbonate.
Report Facts
Medication error rate: 13
Medication errors: 4
Medication opportunities: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Named in medication error findings for failure to administer medications and notify physician | |
| Licensed Practical Nurse (LPN) #1 | Named in medication error findings for failure to administer medication and medication administration error | |
| Director of Nursing (DON) | Interviewed regarding medication availability and communication |
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: Nov 13, 2024
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to ensure residents' call lights were answered in a timely manner.
Complaint Details
The complaint investigation found substantiated issues with call light response times, with residents reporting waits from 30 minutes up to three hours. Staff interviews confirmed inadequate staffing and failure to meet timely response expectations.
Findings
The facility failed to ensure residents' call lights were answered promptly, causing feelings of neglect among residents. Observations and interviews confirmed multiple instances where staff, including the nursing home administrator and director of nursing, did not respond timely or at all to activated call lights.
Deficiencies (1)
F 0550: The facility failed to honor residents' rights to a dignified existence and timely communication by not responding promptly to call lights for two of three sampled residents. Multiple observations showed staff walking past activated call lights without answering them, including instances involving the nursing home administrator and director of nursing.
Report Facts
Residents affected: 2
Call light response time: 14
Call light wait time: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Mentioned in relation to call light response failures and interview about staff expectations. | |
| Director of Nursing (DON) | Mentioned in relation to call light response failures and presence during observations. | |
| CNA #1 | 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
Routine state inspection survey conducted to assess compliance with regulatory requirements related to resident rights, grievance handling, discharge procedures, restorative nursing, fall prevention, respiratory care, and medication management.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and respect, inadequate response to resident council grievances, incomplete discharge summaries, failure to ensure proper use of restorative splints, inadequate supervision and fall prevention measures, improper oxygen therapy management, and medication storage and labeling deficiencies.
Deficiencies (8)
F 0550: Facility failed to ensure Resident #33's care needs were discussed in a dignified manner and staff made the resident feel responsible for staff quitting and inadequate care.
F 0565: Facility failed to promptly address and resolve ongoing resident council grievances, resulting in residents feeling unheard and concerns about call light response, staff attitudes, phone use, and shower temperatures remaining unresolved.
F 0585: Facility failed to provide prompt efforts to resolve Resident #33's grievance regarding CNA #6's unavailability at scheduled care times, with inadequate follow-up and monitoring.
F 0661: Facility failed to ensure discharge summaries for Resident #75 included a recapitulation of stay, final status, and complete follow-up instructions.
F 0688: Facility failed to ensure Resident #6 wore her right hand splint as ordered for contracture management and did not document refusals or encourage use consistently.
F 0689: Facility failed to provide adequate supervision to prevent choking for Resident #55 and failed to conduct thorough fall investigations with timely interventions for Resident #63.
F 0695: Facility failed to ensure Resident #55 had oxygen therapy administered as ordered, with appropriate monitoring, correct flow settings, and accurate documentation.
F 0761: Facility failed to remove expired medications and undated opened supplements from medication carts, and failed to consistently monitor and document medication refrigerator temperatures.
Report Facts
Residents reviewed: 29
Residents affected by dignity deficiency: 1
Residents affected by resident council grievance deficiency: 6
Residents affected by grievance follow-up deficiency: 1
Residents reviewed for discharge: 3
Residents affected by discharge summary deficiency: 1
Residents reviewed for restorative services: 29
Residents affected by restorative splint deficiency: 1
Residents reviewed for fall prevention: 29
Residents affected by fall prevention deficiency: 2
Residents reviewed for oxygen use: 4
Residents affected by oxygen therapy deficiency: 1
Medication carts reviewed: 5
Medication storage refrigerators reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Named in Resident #33 care time and grievance findings |
| LPN #3 | Licensed Practical Nurse | Named in Resident #33 grievance and care findings |
| Unit Manager | Involved in Resident #33 care and grievance follow-up | |
| Infection Preventionist Nurse | Investigated Resident #33 grievance | |
| Nursing Home Administrator | Oversaw grievance and other facility issues | |
| Director of Nursing | Oversaw grievance and other facility issues | |
| CNA #4 | Certified Nurse Aide | Named in Resident #6 splint use findings |
| CNA #5 | Certified Nurse Aide | Named in Resident #6 splint use findings and oxygen use |
| Registered Nurse #2 | Registered Nurse | Named in medication cart and oxygen use findings |
| LPN #1 | Licensed Practical Nurse | Named in medication cart and medication storage findings |
| Unit Manager | Named in fall prevention and oxygen use findings | |
| Interim Director of Nursing | Named in oxygen use and fall prevention findings |
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 |
Inspection Report
Deficiencies: 8
Date: May 12, 2022
Visit Reason
The inspection was conducted as a regulatory survey including complaint investigations and infection control review.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to provide timely pain management, medication errors, improper food storage, inadequate COVID-19 testing procedures, and failure to maintain and enforce COVID-19 vaccination and PPE policies for staff.
Deficiencies (8)
F 0558: The facility failed to ensure Resident #18's call light was within reach, limiting the resident's ability to summon staff assistance.
F 0565: The facility failed to provide timely resolution of resident grievances related to food quality and roommate television noise.
F 0695: The facility failed to administer oxygen to Resident #39 according to physician orders, with oxygen set at 3 LPM instead of 4 LPM.
F 0697: The facility failed to provide timely pain management for Resident #163, who waited over an hour for pain medication and lacked a pain care plan.
F 0760: The facility failed to prevent significant medication errors for Residents #58 and #8, including incorrect Lorazepam scheduling and failure to hold insulin per physician orders.
F 0812: The facility failed to ensure food was stored under safe and sanitary conditions, with unlabeled, undated, and expired food items found in nourishment room refrigerators.
F 0886: The facility failed to follow proper COVID-19 testing procedures, including inadequate testing area disinfection, improper staff training, and lack of protective barriers during staff rapid antigen testing.
F 0888: The facility failed to maintain and track COVID-19 vaccination status for all staff and contractors and failed to enforce N95 mask use for unvaccinated staff in patient care areas.
Report Facts
Residents in sample: 32
Lorazepam doses administered: 56
Pain medication delay: 72
Oxygen flow rate: 4
Oxygen flow rate observed: 3
Expired milk date: Mar 7, 2022
Food expiration limit: 3
Unvaccinated staff count: 4
Invalid rapid COVID-19 test: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #3 | Dietary Aide | Performed invalid COVID-19 rapid test and lacked proper training |
| LPN #4 | Licensed Practical Nurse | Unvaccinated staff observed wearing surgical mask instead of N95 |
| CNA #7 | Certified Nurse Aide | Unvaccinated staff observed wearing surgical mask instead of N95 |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen administration, pain management, medication errors, and COVID-19 policies |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding COVID-19 outbreak, testing procedures, vaccination tracking, and infection control |
| Hospice Registered Nurse | Hospice Registered Nurse | Provided clarification on Lorazepam order for Resident #58 |
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