Villa Manor Care Center: Staffing Failures Leave Residents Soiled - CO
That account came from a certified nursing assistant, one of four who told federal inspectors on March 19, 2025 that the facility routinely ran its residential unit with two CNAs when three or four were needed.
CNA #4 described what happened when the count dropped to two: aides would try to track down a nurse to help. That search could eat up half an hour. When they brought their concerns to management, he said, they were told to work it out.
CNA #2 had worked the unit for the prior two evenings on short staff. She said incontinence care didn't always get done. Oral care didn't always get done. Scheduled showers didn't get done. The restorative CNA, whose job is rehabilitative work with residents, got pulled to cover the floor instead. Management, she said, did not come down to help.
She said she wished the facility would use agency staff when they were short. She said the CNAs were doing the best they could.
CNA #3 said the unit was short staffed often. CNA #4 said the shortage delayed personal care and pushed showers off the schedule entirely.
The licensed practical nurse on the unit put it plainly. Two CNAs for 40-some residents. She said she tried to help but had physical limitations. When a resident required two people to assist with a change, that resident waited. Stayed wet. Stayed soiled. Until someone else arrived.
The director of nursing told inspectors a different story.
She said she was super confident about the facility's staffing. She said if a CNA called off, managers would step in to help with transfers and showers. She said agency staff were available if needed. She said she wasn't aware residents weren't getting their showers. She thought they were.
Asked to explain the gap between what four frontline staff described and what she believed was happening, the director offered a different explanation: documentation errors. She thought the showers were probably being given and just not recorded correctly.
The regional vice president, interviewed 18 minutes after the director of nursing, landed on the same answer. Missed showers, she said, were a documentation issue. The director of nursing needed to provide education on documentation and time management.
Four CNAs and a nurse described residents sitting in soiled briefs, showers skipped, oral care skipped, the restorative aide pulled off her assigned work to cover gaps that management said didn't exist. The two most senior people at the facility, when confronted with that, said the paperwork probably just needed fixing.
The inspection cited the deficiency as causing minimal harm or potential for actual harm, affecting some residents. That classification sits at the lower end of the federal scale. It does not capture what the LPN described: a resident who needed two people to be changed, lying wet, waiting for a second shift to begin.
Villa Manor Care Center sits on West Mississippi Avenue and is licensed to serve a population that, by definition, cannot manage their own hygiene, cannot wait out a staffing gap the way a person in better health might. The CNAs said they understood that. They said they were doing the best they could with what they had.
Management said they were confident everything was fine.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
VILLA MANOR CARE CENTER in LAKEWOOD, CO was cited for violations during a health inspection on March 19, 2025.
CNA #4 described what happened when the count dropped to two: aides would try to track down a nurse to help.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.