Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 3, 2024
Visit Reason
The inspection was conducted in response to complaints regarding resident grievances not being addressed, allegations of resident abuse, and failure to post nurse staffing information as required.
Complaint Details
The complaint investigation substantiated allegations that the facility failed to act on resident grievances, failed to protect residents from verbal abuse by RN #1, and failed to post nurse staffing information as required. The police substantiated the abuse allegation against RN #1. The facility delayed investigation and reporting of abuse and did not conduct a complete investigation.
Findings
The facility failed to promptly address resident grievances raised during council meetings, resulting in unresolved concerns about staffing, cleanliness, and call light response times. The facility also failed to protect residents from verbal abuse by a registered nurse, leading to psychosocial harm and substantiated abuse allegations. Additionally, the facility did not consistently post nurse staffing information in a prominent and accessible location and failed to retain staffing records for the required period.
Deficiencies (3)
F 0565: The facility failed to follow up on grievances raised by resident groups during council meetings, resulting in unresolved concerns about staffing, cleanliness, and call light response times.
F 0600: The facility failed to protect residents from verbal abuse by RN #1, who yelled at residents for using call lights and threatened to not respond, causing psychosocial harm to affected residents.
F 0732: The facility failed to post nurse staffing information daily in a prominent, accessible location and did not retain staffing records for 18 months as required.
Report Facts
Residents affected: 11
Resident group interview participants: 7
Resident council meeting months reviewed: 3
Call light wait time: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in verbal abuse findings against residents |
| CNA #1 | Certified Nurse Aide | Witnessed verbal abuse incident and provided statement |
| NHA | Nursing Home Administrator | Provided updates and interviews regarding abuse investigation |
| DON | Director of Nursing | Interviewed regarding grievance follow-up and nurse staffing postings |
| SSD | Social Services Director / Grievance Official | Responsible for grievance processing and follow-up |
| AD | Activity Director | Responsible for resident council meetings and minutes |
| CC | Corporate Consultant | Educated facility leadership on abuse investigation policy |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 9, 2024
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with healthcare regulations and ensure resident safety and care quality at Littleton Care and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, inadequate pressure ulcer care, and failure to maintain an effective infection prevention and control program. Specific issues included lack of physician orders for restraints, improper wound care, and insufficient cleaning practices in resident restrooms.
Deficiencies (6)
F 0604: The facility failed to ensure one resident was free from physical restraints, lacking physician orders for the wander guard and failing to identify it as a restraint on the MDS assessment.
F 0604: The facility failed to document wandering behavior, monitor wander guard placement, and provide structured activities for the resident at risk of elopement.
F 0604: The facility did not assess the need for continued use of the wander guard or justify its ongoing use for the resident.
F 0686: The facility failed to follow physician orders for wound care and did not follow linen recommendations for air mattresses for one resident with a pressure ulcer.
F 0686: A nurse applied wound dressing without cleaning the wound and used incorrect dressing type contrary to physician orders.
F 0880: The facility failed to maintain an infection control program by not properly cleaning resident restrooms, not following surface disinfectant times, and neglecting high touch surfaces.
Report Facts
Sample residents reviewed: 21
Residents affected: 1
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided facility policies and interviewed regarding restraint and wound care deficiencies | |
| Certified Nurse Aide (CNA) #1 | Interviewed about resident wandering and restraint use | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about resident wandering and restraint monitoring | |
| Social Services Director (SSD) | Interviewed about restraint orders and MDS assessment | |
| Registered Nurse (RN) #1 | Interviewed about wound care procedures and deficiencies | |
| Certified Nurse Aide (CNA) #3 | Interviewed about linen use on air mattresses | |
| Housekeeper (HSK) #1 | Interviewed about cleaning practices and disinfectant use | |
| Housekeeping and Laundry Manager (HLM) | Interviewed about cleaning protocols and disinfectant times | |
| Infection Preventionist (IP) | Interviewed about infection control practices and cleaning standards |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 7, 2023
Visit Reason
The investigation was conducted due to a complaint that the facility failed to timely notify the physician of a resident's change in medical condition, specifically regarding new symptoms of numbness in the left leg.
Complaint Details
The complaint investigation found that the facility did not notify the resident's physician in a timely manner about the resident's new symptoms of numbness starting on 3/11/23. The resident's physician and assistant confirmed they were not notified. The facility conducted an internal investigation, provided staff education, and revised policies to prevent recurrence.
Findings
The facility failed to ensure timely notification to the resident's physician about the resident's new symptoms of numbness and weakness in the lower extremities. The deficiency was cited as past noncompliance, and the facility implemented policy revisions and staff education to address the issue.
Deficiencies (1)
F 0580: The facility failed to make a timely notification to the physician of Resident #1's change in medical condition, specifically new numbness in the left leg. Documentation and monitoring of the symptoms over the following 72 hours were also inadequate.
Report Facts
Residents Affected: 3
Investigation start date: 52223
Correction date: 52623
Resident discharge date: 31623
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in failure to notify physician and documentation of resident's condition |
| DON | Director of Nursing | Interviewed regarding facility's response and policy revisions |
Inspection Report
Deficiencies: 2
Date: Sep 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care and facility policies, including communication assistance for residents with aphasia and safe storage of foods brought by family or visitors.
Findings
The facility failed to provide adequate assistance to maintain activities of daily living for a resident with aphasia by not developing a person-centered care plan or staff training on communication aids. Additionally, the facility failed to implement its policy for safe and sanitary storage of foods brought by visitors, lacking a system to monitor and clean personal refrigerators.
Deficiencies (2)
F 0676: The facility failed to provide assistance to maintain activities of daily living for Resident #131 with aphasia by not developing a person-centered care plan or training staff on communication techniques.
F 0813: The facility failed to implement its policy regarding use and storage of foods brought by family or visitors, lacking a system to maintain sanitary food storage in Resident #3's personal refrigerator.
Report Facts
Residents in sample: 18
Residents affected: 1
Residents affected: 1
Inspection Report
Deficiencies: 3
Date: Oct 30, 2019
Visit Reason
The inspection was conducted to evaluate compliance with Medicare/Medicaid regulations including beneficiary notification, environmental safety, and nurse staffing postings.
Findings
The facility failed to provide required Medicare beneficiary notices to some residents, maintain a safe and clean shower room environment, and post accurate daily nurse staffing information including census and hours worked by staff.
Deficiencies (3)
F 0582: The facility failed to provide skilled nursing facility-advanced beneficiary notices (ABN) to two residents after Medicare coverage ended, despite issuing Notice of Medicare Provider Non-Coverage (NOMNC).
F 0584: The facility failed to maintain a safe, clean, and comfortable shower room, including maintaining temperature, securing the toilet, repairing a hole exposing pipes, replacing missing tiles, and preventing garbage overflow.
F 0732: The facility failed to post daily nurse staffing information including census and total number and hours worked by RNs, LPNs, and CNAs on multiple days over three months.
Report Facts
Residents reviewed for beneficiary protection notification: 22
Residents affected by ABN deficiency: 2
Temperature of shower room observed: 66.1
Days missing census on staff posting: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided facility policy and interviewed regarding staffing postings and ABN procedures | |
| Social Services Director | Interviewed about Medicare coverage review process and ABN issuance | |
| Social Services Consultant | Interviewed about previous ABN issuance practices | |
| Consultant Registered Nurse | Provided facility policy and interviewed regarding shower room conditions and staffing postings | |
| Nursing Home Administrator | Interviewed regarding shower room conditions and staffing postings | |
| Certified Nurse Aide | Interviewed about shower room temperature and resident reports | |
| Licensed Practical Nurse | Interviewed about shower room temperature and toilet condition | |
| Maintenance Supervisor | Interviewed about repairs and maintenance of shower room and toilet |
Report
October 3, 2024
Report
January 9, 2024
Report
September 7, 2023
Report
September 14, 2022
Report
October 30, 2019
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