ARVADA, CO - Federal inspectors documented dangerous nutritional failures at Arbor View Care Center after an 85-year-old dementia patient experienced severe weight loss due to inadequate feeding assistance.
Critical Weight Loss Goes Unaddressed
Resident #93 lost 14.1 pounds over three months, dropping from 114.6 pounds at admission to 100.5 pounds by July 2024 - a 12.3% weight loss that posed serious health risks. Despite physician orders requiring "total supervision and assistance with meals," staff repeatedly left the resident to eat alone.
During inspection observations on July 24, inspectors documented that staff provided only brief assistance before leaving the resident unattended. CNA #3 helped with just two bites of a sandwich before departing at 12:24 p.m. When the resident struggled to eat mandarin oranges from a cup, spilling juice but unable to get fruit in her mouth, no staff member assisted.
Another resident at a nearby table eventually tried to help, feeding her a spoonful of oranges before returning to his own meal. The resident's food intake was later recorded as 51-75% despite consuming only one-fourth to one-third of her meal.
Medical Significance of Rapid Weight Loss
Weight loss exceeding 5% in one month or 7.5% in three months is considered severe in nursing home residents. Rapid weight loss in dementia patients can lead to:
- Weakened immune system and increased infection risk - Muscle wasting and reduced mobility - Delayed wound healing - Cognitive decline acceleration - Increased fall risk due to weakness
The facility's own Weight Management policy required weekly monitoring and intervention for residents with significant weight changes, yet meaningful action was delayed for months.
Systemic Staffing Problems Compound Care Issues
The nutritional crisis occurred alongside widespread staffing problems that affected multiple aspects of care. Resident #6 reported that agency staff "frequently said they were understaffed and could not provide showers."
CNA #9, a former shower aide whose position was eliminated under new management, explained that agency staff would "tell the facility staff what they would do and would not do," forcing regular staff to "scramble and do extra work."
The facility had switched to a different staffing agency, but orientation remained inadequate. Agency nurses reported receiving only shift-to-shift reports rather than comprehensive training on individual resident needs and preferences.
Oxygen Therapy Failures Create Additional Risks
Inspectors also identified respiratory care violations affecting two residents requiring oxygen therapy. Resident #21, who had a physician's order for continuous oxygen, was repeatedly observed without her nasal cannula properly positioned.
On multiple occasions, staff failed to ensure the oxygen delivery device remained in place, despite the resident's inability to reposition it herself due to cognitive impairment. Resident #56's CPAP machine had been broken for three months after a physician recommended "service or replacement as soon as possible" in May 2024, yet no action was taken.
Medication Safety Concerns
The facility's medication error rate reached 16.1% - more than three times the maximum allowable 5% rate. Critical errors included:
- Anti-seizure medications administered 23 minutes late - Lactose intolerance medication given over two hours late - Complete omission of prescribed nasal spray medication
These timing failures are particularly dangerous for seizure medications, where delayed administration can trigger breakthrough seizures.
Industry Standards and Required Interventions
Federal regulations require nursing homes to ensure residents receive adequate nutrition and maintain their highest physical well-being. For residents with dysphagia and dementia, this includes:
- Consistent meal assistance per physician orders - Alternative food offerings when intake is poor - Accurate documentation of actual consumption - Prompt intervention when weight loss occurs
The facility's restorative dining program, designed to help residents maintain eating independence, was implemented but poorly executed due to staffing inconsistencies.
Facility Response and Ongoing Monitoring
The Director of Nursing acknowledged that shower preferences were being missed and stated they were "actively working on implementing a new system." For the nutrition violations, a four-ounce nutritional supplement was finally ordered on July 23, 2024 - months after the weight loss began.
The inspection revealed a pattern of delayed responses to serious care issues, raising questions about the facility's quality assurance processes and administrative oversight.
These violations represent actual harm to residents' health and safety, requiring immediate corrective action and ongoing monitoring to prevent future occurrences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbor View Care Center from 2024-07-30 including all violations, facility responses, and corrective action plans.
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