LAKEWOOD, CO - Federal inspectors cited Villa Manor Care Center for failing to maintain adequate nursing staff levels, resulting in vulnerable residents missing the majority of their scheduled showers and experiencing delays in basic personal care.
Critical Understaffing Documented
The March 19, 2025 inspection revealed systematic staffing shortages that directly impacted resident care quality. Documentation showed three residents received a combined total of only 13 showers out of 53 scheduled opportunities between January and March 2025.
Resident #1, who has multiple sclerosis and requires two-person assistance for bathing, received only six showers out of 28 scheduled opportunities during this three-month period. In January alone, she received bathing assistance on just one of six scheduled days.
The facility's own policies required residents to receive assistance with activities of daily living as needed to maintain good hygiene and health.
Staff Report Dangerous Conditions
Certified nursing aide interviews revealed the extent of the staffing crisis. One CNA reported working alone to care for 45 residents, including two who required two-person mechanical transfers for safety. Another aide described working alone for two hours caring for 24 residents.
"Sometimes the facility only had two CNAs to work the unit with 50 residents," one aide told inspectors. "The shortage prevented the CNAs from doing their assigned showers for the residents."
Staff members consistently reported that when they brought concerns to management, they were told to "just do what they could" or to "work it out."
Medical Implications of Hygiene Neglect
Proper bathing serves multiple critical health functions beyond basic cleanliness. For residents with conditions like multiple sclerosis, diabetes, and dementia - as documented among the affected residents - regular hygiene care prevents skin breakdown, infections, and maintains dignity.
Skin integrity becomes particularly crucial for residents with limited mobility. Extended periods without proper cleansing can lead to fungal infections, pressure ulcers, and urinary tract infections. For residents with incontinence, timely cleaning prevents skin maceration and reduces infection risk.
The inspection found that incontinence care was also delayed due to staffing shortages, with one licensed practical nurse noting that residents would "have to stay wet or soiled until a second CNA was available to help."
Regulatory Standards Violated
Federal nursing home regulations require facilities to provide sufficient staffing to meet each resident's needs. The facility's care plans specifically called for regular bathing assistance - four times weekly for Resident #1 and twice weekly for others.
Proper hygiene care requires adequate time and appropriate staffing ratios. Industry standards typically recommend one aide for every 8-12 residents during day shifts, depending on acuity levels. The documented ratio of two aides for 50 residents falls far below these benchmarks.
Management Disconnect
The inspection revealed a significant disconnect between management perception and frontline reality. The Director of Nursing told inspectors she was "super confident about the facility staffing" and believed missed showers were documentation errors rather than actual care gaps.
The regional vice president similarly attributed the problems to documentation issues and suggested the nursing director needed education on time management.
This response contrasts sharply with the detailed accounts from multiple nursing staff members who consistently described inadequate staffing levels affecting their ability to provide basic care.
Broader Care Impacts
The staffing shortage extended beyond bathing assistance. CNAs reported that when working with minimal staff, "incontinence care and oral care did not always get done." Licensed nursing staff acknowledged they would try to help but had physical limitations preventing them from providing hands-on care.
For residents requiring two-person assistance, delays became particularly problematic. Staff reported these residents would have to wait until the next shift change to receive necessary care, potentially remaining in uncomfortable or unsanitary conditions for extended periods.
Facility Response Required
Villa Manor Care Center must now submit a plan of correction addressing how they will ensure adequate staffing levels to meet resident care needs. This includes developing systems to guarantee scheduled personal care is completed and implementing backup plans when staff call in sick.
The citation represents a violation of federal nursing home standards that could impact the facility's Medicare and Medicaid participation if not promptly addressed. Families considering this facility should inquire about current staffing ratios and care completion rates.
The full inspection report provides additional details about the facility's operations and can be accessed through the Centers for Medicare & Medicaid Services nursing home compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Manor Care Center from 2025-03-19 including all violations, facility responses, and corrective action plans.
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