Inspection Reports for
The Suites at Someren Glen
5000 E Arapahoe Rd, Centennial, CO 80122, CO, 80122
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding resident care, specifically focusing on dignity and appropriate assistance with activities of daily living for residents at the facility.
Complaint Details
The complaint investigation focused on allegations that Resident #6 was inappropriately physically redirected without verbal communication, and that Residents #3 and #7 did not receive timely toileting and incontinence care, leading to soiling and potential skin issues. The complaint was substantiated with observations, record reviews, and staff interviews confirming these failures.
Findings
The facility failed to ensure Resident #6 experienced dignified care during redirection by a CNA, and failed to provide timely toileting and incontinence care for Residents #3 and #7, resulting in minimal harm or potential for harm to a few residents.
Deficiencies (2)
Failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, specifically for Resident #6 who was physically redirected without verbal explanation or reassurance.
Failed to provide care and assistance to perform activities of daily living, including timely toileting and incontinence care for Residents #3 and #7.
Report Facts
Residents affected: 3
Observation duration: 3.5
Time without toileting care: 5.07
Time without incontinence care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed and commented on CNA #1's inappropriate physical redirection of Resident #6. |
| Certified Nurse Aide #1 | CNA | Provided inappropriate physical redirection to Resident #6 without verbal communication. |
| Certified Nurse Aide #4 | CNA | Observed providing care to Resident #3, failed to timely change incontinence brief and did not ask about toileting needs. |
| Certified Nurse Aide #5 | CNA | Assisted Resident #3 with water but did not ask about toileting or incontinence care needs. |
| Certified Nurse Aide #2 | CNA | Provided incontinence care to Resident #7 and described typical care schedule. |
| Director of Nursing | DON | Acknowledged CNA #1's inappropriate actions and described facility expectations for resident care and staff education. |
| Assistant Director of Nursing | ADON | Interviewed regarding Resident #3's care timing and toileting assistance. |
| Hospice Aide | HA | Provided shower and incontinence care to Resident #7 and noted skin condition. |
Inspection Report
Routine
Census: 39
Deficiencies: 6
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of practice related to pressure ulcer care and other regulatory requirements in a nursing home setting.
Findings
The facility failed to provide timely and appropriate pressure ulcer care and prevention interventions for two residents, resulting in actual harm. Additionally, deficiencies were found in nurse aide performance evaluations, staffing postings, medication storage and labeling, infection control practices, and nurse aide training.
Deficiencies (6)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents #1 and #27.
Failure to complete annual performance reviews and provide regular in-service education for five certified nurse aides.
Failure to post nurse staffing information including actual hours worked by licensed and unlicensed staff per shift.
Failure to ensure medications and biologicals were stored and labeled properly, including expired medications in medication carts, unlabeled insulin pens, and storage in dormitory style refrigerator/freezer.
Failure to maintain infection prevention and control program, including improper storage of Foley catheter bags and failure to disinfect mechanical lifts between residents.
Failure to ensure certified nurse aides received the required 12 hours of annual in-service training for continued competence.
Report Facts
Residents in sample: 39
Residents affected: 2
Expired medication: 1
Insulin pen open date limit: 28
CNA annual training hours required: 12
CNA #9 training hours completed: 0.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings related to failure to reposition residents and failure to disinfect mechanical lifts |
| LPN #1 | Licensed Practical Nurse | Named in findings related to wound care and repositioning failures |
| LPN #3 | Licensed Practical Nurse | Named in findings related to medication cart observations |
| Wound Care Physician | Interviewed regarding pressure injury assessments and treatment | |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies, wound care, staffing, and training |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding facility policies and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 12, 2020
Visit Reason
The inspection was conducted to investigate complaints related to care plan updates, fall prevention, pain management, food safety, and infection control at the nursing facility.
Complaint Details
The complaint investigation revealed failures in care plan updates for residents #24, #12, and #296; fall prevention failures resulting in falls and injuries for residents #85 and #300; inadequate pain management for resident #32; food safety violations in kitchen and dining areas; and infection control deficiencies including lack of legionella testing and expired hand sanitizer use.
Findings
The facility failed to provide timely updates to residents' comprehensive care plans, ensure effective fall prevention interventions, provide adequate pain management including non-pharmacological interventions, maintain proper food safety and sanitation practices, and implement an effective infection control program including legionella testing and expired hand sanitizer replacement.
Deficiencies (5)
Failure to provide timely updates to residents' comprehensive care plans reflecting current conditions and medication changes.
Failure to ensure effective fall prevention interventions and adequate supervision to prevent falls resulting in major injury.
Failure to provide safe, appropriate pain management including non-pharmacological interventions and effective tracking.
Failure to store, prepare, distribute and serve food in accordance with professional standards including improper thawing, improper cold food temperatures, poor cleanliness, uncovered foods, and undated nutritional shakes.
Failure to maintain an effective infection prevention and control program including lack of legionella water testing and use of expired alcohol-based hand rub.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Expired ABHR dispensers: 12
Temperature readings: 48
Pain level: 8
Fall risk assessment score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered nurse #6 | RN | Interviewed regarding Resident #24's pain management care plan deficiency |
| Director of Nursing | DON | Interviewed regarding care plan update deficiencies and fall prevention |
| Registered nurse #10 | RN | Interviewed regarding care plan development and Resident #296's therapy status |
| Certified Nursing Assistant #6 | CNA | Interviewed regarding fall prevention and non-slip sock compliance |
| Registered nurse #4 | RN | Interviewed regarding fall prevention and safe transfer procedures |
| Dietary Aide #1 | DA | Observed and interviewed regarding improper food handling and serving practices |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding pain reporting for Resident #32 |
| Certified Nursing Assistant #5 | CNA | Interviewed regarding pain reporting for Resident #32 |
| Registered nurse #11 | RN | Interviewed regarding pain management for Resident #32 |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding use of alcohol-based hand rub and infection control |
| Certified Nursing Assistant #8 | CNA | Interviewed regarding use of alcohol-based hand rub and infection control |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 7, 2019
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding psychotropic medication use, food safety and handling, infection prevention and control, and housekeeping practices.
Findings
The facility was found deficient in appropriate use and documentation of psychotropic medications for residents, proper food handling and temperature monitoring, storage of food items, and infection control practices including hand hygiene and sanitization of shared equipment. Housekeeping staff also failed to perform proper hand hygiene between cleaning resident rooms.
Deficiencies (4)
Failure to ensure appropriate use and documentation of psychotropic medications for residents #57 and #78, including lack of tracking non-pharmacological interventions and physician rationale every 14 days for PRN psychotropic medications.
Failure to ensure appropriate use of gloves when handling ready-to-eat foods, failure to obtain and document food temperatures for all menu items, and improper storage of thickened liquids in the main kitchen.
Failure to maintain an infection prevention and control program, including failure to perform hand hygiene between resident contacts and failure to sanitize shared equipment between resident use.
Failure of housekeeping staff to perform proper hand hygiene between cleaning resident rooms.
Report Facts
Residents reviewed for unnecessary medication use: 5
Sample residents: 27
PRN Lorazepam administrations: 3
Temperature of rice pudding: 127.5
Temperature of pureed rice pudding: 127.4
Thickened liquid use-by date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding monitoring of resident behaviors and documentation of non-pharmacological interventions. |
| LPN #2 | Licensed Practical Nurse | Interviewed about tracking resident behaviors and non-pharmacological interventions. |
| Director of Nursing | Director of Nursing (DON) | Provided facility policies and interviewed regarding psychotropic medication review and infection control practices. |
| Pharmacy Service Consultant | Pharmacy Service Consultant (PSC) | Interviewed about medication regimen reviews and recommendations. |
| Housekeeper | Housekeeper (HK) | Observed and interviewed regarding cleaning practices and hand hygiene. |
| Housekeeping Supervisor | Housekeeping Supervisor (HKS) | Interviewed about training housekeeping staff on cleaning procedures and hand hygiene. |
| Building Operations Director | Building Operations Director (BOD) | Interviewed about expectations for housekeeping staff hand hygiene. |
| Certified Nurse Aides #2, #3, #4 | Certified Nurse Aides (CNAs) | Observed failing to perform hand hygiene between resident contacts and sanitizing shared equipment. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Observed and interviewed regarding sanitization of pulse oximeter and blood pressure cuff. |
| Registered Dietitian | Registered Dietitian (RD) | Observed and interviewed regarding food handling and glove use. |
| Director of Dining Services | Director of Dining Services (DDS) | Provided policies and interviewed regarding food temperature monitoring and storage. |
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