Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where Resident #4 received another resident's medications.
Complaint Details
The complaint was substantiated as Resident #4 was confirmed to have received another resident's medications on 5/15/25, resulting in dizziness and stomachache. The licensed practical nurse who administered the incorrect medications was an agency nurse who did not return to the facility. The Director of Nursing provided medication administration education to all nurses after the incident.
Findings
The facility failed to ensure Resident #4 was free from significant medication errors, specifically administering medications intended for another resident. The error involved Lisinopril 40 mg, duloxetine 60 mg, and bupropion 300 mg ER, which Resident #4 did not have physician orders for. The licensed practical nurse (LPN) who administered the wrong medications was an agency staff nurse.
Deficiencies (1)
Facility failed to ensure Resident #4 did not receive another resident's medications.
Report Facts
Medication dosages administered incorrectly: 40
Medication dosages administered incorrectly: 60
Medication dosages administered incorrectly: 300
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse (Agency Staff) | Administered incorrect medications to Resident #4 |
| Director of Nursing | Director of Nursing (DON) | Notified of medication error and provided medication administration education after the incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error involving Resident #12, specifically a failure to administer warfarin as ordered, which placed the resident at risk for blood clots and serious harm.
Complaint Details
The complaint investigation found that Resident #12 missed warfarin doses from 2/21/25 to 2/27/25 due to a transcription error, leading to a significant reduction in PT/INR levels and increased risk of blood clot. Resident #12 developed a blood clot in the right leg and required an above the knee amputation. The facility corrected the deficient practice prior to the onsite investigation and implemented a plan of correction including staff education and monitoring.
Findings
The facility failed to transcribe a physician's order for warfarin for Resident #12, resulting in seven days without anticoagulant medication, a non-therapeutic PT/INR level, and ultimately a blood clot leading to an above the knee amputation. The facility implemented corrective actions including staff education and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure Resident #12's 2/21/25 physician's order for warfarin was transcribed into the EMR and medication administration record, resulting in missed anticoagulant doses for seven days.
Report Facts
Missed warfarin doses: 7
INR goal range: 2.5
INR goal range: 3.5
INR level: 4.84
INR level: 3.12
INR level: 0.97
INR level: 0.92
Number of licensed nursing staff educated: 16
Date of compliance: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA #1 | Nursing Home Administrator | Provided the corrective action plan and timeline of investigation regarding Resident #12's medication error. |
| DON #1 | Director of Nursing | Reported Resident #12's missed warfarin doses, suspended RN #1, and participated in staff education and corrective actions. |
| RN #1 | Registered Nurse | Entered INR results and verbal orders but failed to transcribe the physician's order for warfarin into the EMR, leading to missed doses. |
| RN #2 | Registered Nurse | Interviewed about proper transcription of physician's orders for warfarin and monitoring INR levels. |
| RN #3 | Registered Nurse | Interviewed about entering physician's orders into the EMR. |
| LPN #1 | Licensed Practical Nurse and Unit Manager | Assisted with staff education after the incident and reported clinical observations of Resident #12's leg condition. |
| LPN #2 | Licensed Practical Nurse | Discovered missed warfarin doses on 2/27/25 and reported to DON and physician. |
| LPN #3 | Licensed Practical Nurse | Reported on staff education regarding warfarin administration and transcription. |
| MD | Medical Director | Interviewed about Resident #12's condition and missed warfarin doses. |
| PHY | Physician | Interviewed about physician orders and facility's warfarin management issues. |
| CRP | Clinical Resource Person | Confirmed missed warfarin doses for Resident #12 during interview. |
| [NAME] | Pharmacist | Provided expert opinion on warfarin dosing, INR goals, and consequences of missed doses. |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to assess the safety, cleanliness, and comfort of the nursing home environment, focusing on ensuring the facility provided a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Findings
The facility failed to ensure that two ceiling swamp cooler vents, two shower rooms, and eight mechanical rooms were thoroughly cleaned, free from debris, and did not contain black discoloration on any surfaces. Multiple areas showed sheetrock damage, water leaks, non-functional exhaust fans, and unkempt floors, posing potential risks to residents.
Deficiencies (3)
Two ceiling swamp cooler vents had missing vent louvers and dark debris with ceiling damage.
Shower rooms had water dripping from showerheads, non-functional exhaust fans, debris, brown and black discoloration on floors and walls.
Eight mechanical rooms had sheetrock damage, black discoloration, unkempt floors, water leaks, dead gnats, cracked paint, rusty vents, and holes in walls.
Report Facts
Residents affected: Many residents were affected by the deficiencies noted.
Residents moved: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Provided the Safe and Homelike Environment policy. | |
| Maintenance Supervisor (MS) | Agreed with observations and described work order process. | |
| Unit Manager (UM) #1 | Agreed with observations during environmental tour. | |
| Accounts Manager (AM) | Agreed with observations during environmental tour. | |
| Unit Manager (UM) #2 | Reported service contractor visit and resident moves for repairs. | |
| Nursing Home Administrator (NHA) | Interviewed via conference call regarding new management and awareness of black discoloration. |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 11, 2024
Visit Reason
The inspection was conducted as a routine state survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to follow PASRR level II recommendations, inadequate assistance with activities of daily living, failure to provide appropriate treatment and care according to physician orders, inadequate fall prevention and post-fall interventions, medication administration errors including wrong resident medication and incorrect timing of opioid administration, and failure to maintain proper infection control practices.
Deficiencies (8)
Failed to ensure level II preadmission screening and resident review (PASRR) were completed and followed for Resident #33.
Failed to provide eating assistance for Resident #31 who required supervision and cueing and was at high risk for weight loss.
Failed to follow hospital physician orders for Resident #35's cervical neck brace, including removal after six weeks, skin monitoring, and ensuring follow-up appointments.
Failed to properly support and position Resident #51 in her wheelchair and failed to evaluate wheelchair positioning for over a year.
Failed to complete root cause analysis and implement person-centered fall interventions for Residents #33 and #35 and failed to ensure RN assessment after falls.
Failed to ensure Resident #51 received correct medications and failed to monitor and follow up after multiple wrong medications were administered.
Failed to administer Resident #70's opioid medication according to physician's scheduled orders, with multiple doses given too early or too late.
Failed to maintain infection control by improper cleaning and disinfecting of resident rooms and equipment, including improper storage and cleaning of nebulizer equipment.
Report Facts
Residents reviewed: 32
PASRR sample residents: 2
Residents with PASRR deficiency: 1
Residents with ADL assistance deficiency: 1
Residents with treatment and care deficiencies: 2
Residents with fall prevention deficiencies: 2
Residents with medication errors: 2
Residents affected by infection control deficiencies: 1
Medication administration errors: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered multiple wrong medications to Resident #51 |
| LPN #1 | Licensed Practical Nurse | Provided assessment and interview regarding Resident #33 falls |
| LPN #2 | Licensed Practical Nurse | Interviewed about nebulizer storage and infection control |
| DON | Director of Nursing | Interviewed multiple times regarding deficiencies in medication administration, fall prevention, and care planning |
| QM | Quality Mentor | Provided facility policies and interviewed regarding PASRR and follow-up appointments |
| NHA | Nursing Home Administrator | Interviewed regarding fall prevention and medication administration policies and corrective actions |
| HSK #1 | Housekeeper | Observed cleaning deficiencies in resident rooms |
| HSKS | Housekeeping Supervisor | Interviewed regarding cleaning procedures and deficiencies |
| ADON | Assistant Director of Nursing | Interviewed regarding medication error grievance and follow-up |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 15, 2022
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and psychotropic medication management, as well as to assess medication error rates and infection control practices during medication administration.
Findings
The facility failed to ensure proper infection control during medication administration by an LPN who touched medications with bare hands without sanitizing. The facility also failed to ensure appropriate management of psychotropic medications for three residents, including lack of gradual dose reductions, inadequate behavior tracking, missing risk versus benefit statements, and incomplete care plans. Additionally, medication error rates were high, with 10 errors out of 25 opportunities (40%), primarily due to late administration of medications for one resident.
Deficiencies (3)
Licensed practical nurse administered medications by touching them with bare hands without sanitizing, risking contamination.
Failed to ensure residents were free of unnecessary psychotropic medications, including lack of risk versus benefit statements, inadequate behavior tracking, and missing non-pharmacological interventions.
Medication error rate was 40%, with medications administered late beyond the allowed administration window.
Report Facts
Medication error rate: 40
Medication administration window: 60
Number of residents reviewed for psychotropic medications: 6
Number of residents affected by psychotropic medication deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Observed administering medications improperly by touching medications with bare hands and administering medications late |
| ADON | Assistant Director of Nursing | Provided facility policies, conducted education with LPN #4, and confirmed medication administration windows and errors |
| DON | Director of Nursing | Provided psychotropic medication policy, confirmed medication administration windows and errors, and discussed care plan requirements |
| NHA | Nursing Home Administrator | Discussed psychotropic medication management, risk versus benefit statements, behavior tracking, and facility performance improvement plan |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #6's behaviors and documentation practices |
| CNA #4 | Certified Nurse Aide | Interviewed regarding Resident #6's behaviors |
| CNA #5 | Certified Nurse Aide | Interviewed regarding Resident #6's behaviors |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding non-pharmacological interventions and PRN medication reassessment |
| RN #1 | Registered Nurse | Interviewed regarding non-pharmacological interventions and PRN medication reassessment |
Inspection Report
Deficiencies: 0
Date: Sep 2, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Westlake Health and Rehabilitation Center, summarizing the results of a regulatory survey completed on 09/02/2021.
Findings
No health deficiencies were found during the survey.
Viewing
Loading inspection reports...
