Inspection Reports for
Silver Heights Skilled Nursing and Rehabilitation
4001 HOME ST, CASTLE ROCK, CO, 80108-2802
Back to Facility Profile7 Reports
Inspection Report — Apr 3, 2025
Annual Inspection
Date: Apr 3, 2025
Visit Reason
Annual inspection of Silver Heights Skilled Nursing and Rehabilitation to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide a homelike environment, inadequate assistance with activities of daily living, failure to manage contractures, inadequate fall prevention and medication management, improper medication storage, failure to provide timely dental services, and deficiencies in infection control practices.
Deficiencies (9)
F 0584: The facility failed to provide residents with hand towels daily in eight of 36 rooms, impacting residents' comfort and homelike environment.
F 0677: The facility failed to provide timely toileting assistance or incontinence care for Resident #24, who went over five hours without being checked or assisted.
F 0688: The facility failed to develop a comprehensive care plan and provide recommended contracture management for Resident #12's left hand contracture.
F 0689: The facility failed to identify the root cause of Resident #259's falls and implement effective person-centered interventions to prevent accidents.
F 0758: The facility failed to ensure proper justification and consent for psychotropic medications for Residents #259, #15, and #10, including lack of documentation of behaviors and side effect consents.
F 0761: The facility failed to store vaccines and insulin pens within the appropriate refrigerated temperature range of 36 to 46 degrees Fahrenheit.
F 0791: The facility failed to assist Resident #12 to obtain timely dental services, with no documentation of follow-up on a dental referral from November 2024.
F 0880: The facility failed to maintain an infection control program including proper hand hygiene and clean technique during wound care, sanitary cleaning of resident rooms, proper laundry handling, and labeling and storage of residents' personal items.
F 0883: The facility failed to implement policies and procedures to document annual offering of influenza and pneumococcal vaccines and failed to administer pneumococcal vaccine after consent for Resident #43.
Report Facts
Rooms without towels: 8
Residents in sample: 30
Residents affected by toileting deficiency: 1
Residents affected by contracture deficiency: 1
Residents affected by fall prevention deficiency: 1
Residents affected by medication management deficiency: 3
Medication storage refrigerator temperature: 50
Residents affected by dental services deficiency: 1
Residents affected by infection control deficiency: 3
Residents affected by immunization deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in toileting assistance and fall prevention findings. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including toileting, contracture management, fall prevention, medication management, infection control, and immunizations. |
| NHA | Nursing Home Administrator | Interviewed regarding multiple deficiencies including infection control, dental services, medication management, and immunizations. |
| RN #1 | Registered Nurse | Interviewed regarding fall prevention and medication management. |
| RN #2 | Registered Nurse | Interviewed regarding fall prevention. |
| MTD | Maintenance Director / Housekeeping Supervisor | Interviewed regarding infection control and laundry practices. |
| LA | Laundry Aide | Interviewed regarding laundry and gown practices. |
Inspection Report — Apr 3, 2025
Complaint Investigation
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to investigate complaints related to abuse, inadequate care, and failure to provide ancillary services at Silver Heights Skilled Nursing and Rehabilitation.
Complaint Details
The investigation was complaint-driven, focusing on allegations of abuse, inadequate care, and failure to provide ancillary services. The abuse incidents were substantiated, and failures in care and service coordination were confirmed.
Findings
The facility substantiated physical abuse incidents involving residents, failed to provide timely toileting assistance for one resident, and did not ensure timely follow-up on a dental referral for another resident. The overall harm level was minimal with few residents affected.
Deficiencies (3)
F 0600: The facility failed to protect residents #15 and #42 from physical abuse by other residents, substantiating willful abuse incidents.
F 0677: The facility failed to provide timely toileting assistance or incontinence care for Resident #24, resulting in over five hours without care.
F 0791: The facility failed to ensure a dental referral was followed up timely for Resident #12, delaying necessary dental treatment.
Report Facts
Sample residents reviewed: 30
Residents affected by abuse: 2
Residents affected by toileting care deficiency: 1
Residents affected by dental referral deficiency: 1
BIMS scores: 11
BIMS score: 12
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Witnessed abuse incident between Resident #13 and Resident #15 | |
| Director of Nursing (DON) | Assessed residents, interviewed involved parties, and substantiated abuse incidents | |
| Nursing Home Administrator (NHA) | Interviewed regarding abuse incidents and facility policies | |
| CNA #1 | Certified Nurse Aide | Provided incontinence care to Resident #24 and interviewed about toileting assistance |
Inspection Report — Nov 7, 2024
Complaint Investigation
Date: Nov 7, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding medication administration, resident abuse, activities of daily living assistance, pharmaceutical services, and medical record documentation at Silver Heights Skilled Nursing and Rehabilitation.
Complaint Details
The investigation was complaint-driven, focusing on medication refusal notification, resident-to-resident abuse, inadequate ADL assistance, drug diversion, and inaccurate medical documentation. The abuse allegation was substantiated. Drug diversion was reported to police and state agency. Other complaints were verified through record review and staff interviews.
Findings
The facility was found deficient in timely physician notification for medication refusals, failure to protect a resident from physical abuse by another resident, inadequate assistance with activities of daily living including incontinence care and meal encouragement, failure to prevent drug diversion of a controlled substance, and inaccurate documentation of resident skin assessments.
Deficiencies (5)
F 0580: The facility failed to notify Resident #15's physician timely when the resident consistently refused anticoagulant medication, Eliquis, despite multiple refusals documented in medication administration records.
F 0600: The facility failed to protect Resident #1 from physical abuse by Resident #2, substantiated by an incident where Resident #2 hit Resident #1 causing minor injuries.
F 0600: The facility failed to provide necessary assistance with activities of daily living for Residents #10 and #16, including timely incontinence care and meal encouragement.
F 0755: The facility failed to prevent drug diversion of Resident #18's Ativan, with 44 tablets missing due to incomplete narcotic counts during shift changes.
F 0842: The facility failed to maintain accurate medical records for Residents #4 and #12, including inaccurate skin assessments and documentation of pressure injuries and wounds.
Report Facts
Medication refusals: 40
Medication refusals: 6
Missing controlled substance tablets: 44
Call light response time: 37
Pressure injury measurement: 6
Pressure injury measurement: 3.5
Pressure injury measurement: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #15's medication refusals and education. |
| ADON | Assistant Director of Nursing | Interviewed regarding medication refusal procedures and resident abuse investigation. |
| NHA | Nursing Home Administrator | Interviewed regarding drug diversion investigation and staff education. |
| DON | Director of Nursing | Interviewed regarding drug diversion investigation and documentation accuracy. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #10's meal assistance and toileting. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #10's meal assistance needs. |
| CNA #4 | Certified Nurse Aide | Witnessed resident-to-resident altercation between Resident #1 and Resident #2. |
| Nurse Practitioner | Nurse Practitioner | Provided follow-up notes on Resident #15's medication and Resident #4's foot condition. |
Inspection Report — Oct 19, 2023
Complaint Investigation
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident abuse, failure to provide appropriate care, and other regulatory compliance issues at Silver Heights Skilled Nursing and Rehabilitation.
Complaint Details
The complaint investigation substantiated verbal abuse by a staff member toward Resident #62, failure to provide adequate ADL assistance to Residents #1 and #11, failure to follow physician orders for Resident #51, inadequate supervision leading to falls for Resident #14, failure to provide proper urostomy care for Resident #7, lack of annual staff performance reviews and training, unlocked medication carts, and deficiencies in the water management program for Legionella prevention.
Findings
The facility was found to have multiple deficiencies including verbal abuse of a resident by a staff member, failure to provide adequate assistance with activities of daily living, failure to follow physician orders for treatment, inadequate supervision to prevent falls, failure to provide appropriate urostomy care, lack of annual performance reviews and training for staff, unlocked medication carts, and an incomplete water management plan for Legionella prevention.
Deficiencies (8)
F 0600: The facility failed to ensure Resident #62 was kept free from verbal abuse and threats by a staff member, confirmed by investigation and video surveillance.
F 0676: The facility failed to ensure Residents #1 and #11 received showers and that their care plans addressed shower refusals and preferences.
F 0684: The facility failed to provide appropriate treatment and care for Resident #51 by not scheduling a cardiology appointment and not notifying the physician of chest pain.
F 0689: The facility failed to ensure Resident #14 received adequate supervision to prevent falls, despite activated call lights and calls for help.
F 0691: The facility failed to consistently provide urostomy care for Resident #7 and lacked physician orders for urostomy care.
F 0730: The facility failed to complete annual performance reviews and in-service education for five staff members including CNAs and an activities aide.
F 0761: The facility failed to ensure medication carts were locked when unattended or out of direct line of sight, risking resident access to medications.
F 0880: The facility failed to include adequate control measures for monitoring and preventing Legionella and waterborne pathogens growth in the water management plan.
Report Facts
Residents reviewed: 32
Dates of survey completion: Oct 19, 2023
BIMS scores: 9
BIMS scores: 12
BIMS scores: 13
BIMS scores: 9
BIMS scores: 15
Fall incidents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Named in verbal abuse finding toward Resident #62 |
| LPN #1 | Licensed Practical Nurse | Witnessed verbal abuse incident involving RN #5 and Resident #62 |
| DON | Director of Nursing | Interviewed regarding multiple findings including abuse, care failures, and staff training |
| CNA #8 | Certified Nurse Aide | Interviewed regarding shower refusals for Residents #1 and #11 |
| RN #4 | Registered Nurse | Interviewed regarding shower assistance and refusals |
| ADON | Assistant Director of Nursing | Interviewed regarding failure to notify physician of Resident #51's chest pain |
| CNA #2 | Certified Nurse Aide | Interviewed regarding supervision and falls of Resident #14 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding medication cart security and urostomy care orders |
| RN #1 | Registered Nurse | Interviewed regarding medication cart security |
| AA #1 | Activities Aide | Interviewed regarding lack of annual performance reviews and training |
| HRD | Human Resources Director | Interviewed regarding lack of annual performance reviews and training |
| NHA | Nursing Home Administrator | Interviewed regarding abuse investigation, staff training, and water management |
| RMS | Regional Maintenance Supervisor | Interviewed regarding water management plan and Legionella monitoring |
| MS | Maintenance Supervisor | Interviewed regarding water management and Legionella monitoring |
Inspection Report — Apr 26, 2023
Routine
Date: Apr 26, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on housekeeping and environmental conditions.
Findings
The facility failed to maintain cleanliness and good repair in resident rooms and bathrooms across multiple units. Observations and resident interviews revealed issues such as stained and sticky floors, unclean bathrooms, odors, and incomplete housekeeping tasks despite ongoing audits and improvement efforts.
Deficiencies (1)
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment in resident rooms and bathrooms, with issues including stained floors, sticky substances, unclean toilets, missing call light pull strings, and persistent odors.
Report Facts
Housekeeping cleaning audits: 3
Resident group interview participants: 5
Resident council meeting dates: 3
Housekeeping staff count: 3
Inspection Report — Jul 21, 2022
Date: Jul 21, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, medication administration, staff competencies, dementia care, respiratory care, restraint use, and hospice services at Silver Heights Skilled Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to maintain a sanitary and safe environment, inadequate assessment and care planning for restraints, improper respiratory care and oxygen administration, lack of nursing staff competencies, failure to provide appropriate dementia care, medication administration errors exceeding 5%, and inadequate hospice care planning and coordination.
Deficiencies (7)
F 0584: The facility failed to maintain a sanitary, orderly, and comfortable environment in 20 of 31 resident rooms, hallways, and the kitchen, including issues with grease buildup, water damage, peeling paint, and damaged walls and floors.
F 0604: The facility failed to comprehensively assess and care plan the use of personal alarms and wander guards as restraints for one resident, failing to attempt alternate interventions prior to implementation.
F 0695: The facility failed to ensure residents received proper respiratory treatment, including lack of physician order for continuous oxygen use for one resident and failure to administer oxygen per order for another.
F 0726: The facility failed to ensure nursing staff, including facility and agency nurses and aides, completed required competencies prior to providing skilled services.
F 0744: The facility failed to provide appropriate treatment and services for residents with dementia, including inadequate person-centered care approaches, insufficient supervision of a supervised smoker, and lack of psychiatric and psychological services for residents with behavioral disturbances.
F 0759: The facility failed to ensure medication error rates were below 5%, with a 12% error rate observed related to late medication administration for one resident.
F 0849: The facility failed to ensure hospice services met professional standards, lacking a hospice care plan, failing to identify responsibilities and frequency of visits, and not coordinating care plans between hospice and facility for one resident.
Report Facts
Medication error rate: 12
Resident sample size: 25
Resident rooms with environmental issues: 20
Resident rooms observed: 31
Residents reviewed for restraints: 25
Residents reviewed for respiratory care: 25
Residents reviewed for competencies: 4
LPNs reviewed for competencies: 2
RNs reviewed for competencies: 2
Residents reviewed for dementia care: 5
Residents reviewed for hospice services: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified nurse aide #4 | CNA | Interviewed regarding restraint use and hospice services |
| Licensed practical nurse #1 | LPN | Interviewed regarding restraint use, respiratory care, medication administration, and hospice services |
| Director of Nursing | DON | Interviewed regarding medication administration, respiratory care, hospice care, and staff competencies |
| Interim Nursing Home Administrator | INHA | Interviewed regarding restraint use, dementia care, and hospice services |
| Social Services Director | SSD | Interviewed regarding dementia care, smoking supervision, and hospice services |
| Certified nurse aide #7 | CNA | Interviewed regarding dementia care and resident behaviors |
| Registered nurse #1 | RN | Interviewed regarding smoking supervision |
| Activity Director | AD | Interviewed regarding dementia care and resident activities |
| Interim Director of Nursing | IDON | Interviewed regarding staff competencies |
Report
6 CMS Surveys
CMS Survey — Apr 26, 2023
Apr 26, 2023
CMS Survey — Nov 7, 2024
Nov 7, 2024
CMS Survey — Apr 3, 2025
Apr 3, 2025
CMS Survey — Jul 21, 2022
Jul 21, 2022
CMS Survey — Oct 19, 2023
Oct 19, 2023
CMS Survey — Apr 3, 2025
Apr 3, 2025
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