Villa Manor Care Center: Staffing Failures Leave Residents Soiled - CO
That triage system, described by a nursing assistant during a March 19 inspection, was how the facility managed a staffing shortage that left some residents sitting in soiled clothing until the next shift arrived.
The unit housed more than forty residents. Two CNAs were a common configuration. When a resident required a two-person transfer, which was often, one aide had to stop everything and hunt for a second person to help. That search could take 20 to 30 minutes, according to CNA #4, who was interviewed that afternoon. If no second CNA was available, the resident could wait up to an hour, according to a separate nursing assistant interviewed the same day.
Scheduled showers weren't getting done. Incontinence care was being passed to the evening shift. When CNAs brought their concerns to management, CNA #4 said, they were told to work it out.
The licensed practical nurse on the unit told inspectors the facility had been short on CNAs for a while. She said she tried to help but had physical limitations. She confirmed that residents requiring two-person assistance sometimes had to stay wet or soiled until the next CNA came on shift. Not until someone else arrived. Not after a short wait. Until the next shift.
The Director of Nursing, interviewed at 3:37 p.m. that day, said she didn't know why showers weren't being completed, and thought it might be a documentation error. She said she was "super confident" about staffing at the facility. She said she was not aware there was an issue with showers or activities of daily living. She believed residents were receiving care.
The regional vice president, interviewed eighteen minutes later, offered a similar explanation. Missed showers were a documentation issue. The Director of Nursing needed to provide education about documentation and time management. She noted that the facility's nursing home administrator had only been on the job for three days. She said the facility had experienced some staff turnover and had recently raised CNA pay. Then she said something that stood out: she worried about the perception of families and staff when it came to staffing.
Not the staffing itself. The perception of it.
The gap between what the CNAs described and what management told inspectors was direct and specific. The nursing assistants gave inspectors times: 20 to 30 minutes to find a nurse. Up to an hour waiting for a second aide. Incontinence care triaged by type of soiling. The DON gave inspectors a feeling: super confident. The RVP gave inspectors a reframe: documentation education.
Neither offered an explanation for why three separate frontline staff, interviewed individually, described the same pattern in consistent detail.
The inspection found the harm level to be minimal or potential for actual harm, and noted that some residents were affected. That language is regulatory shorthand. What it describes, in this case, is a unit where the people responsible for the most basic elements of human dignity — being clean, being dry, not being left in waste — were systematically unable to do that work, and where the people above them either didn't know or didn't say so when federal inspectors arrived.
A nursing assistant told inspectors that when they raised concerns with management, they were told to work it out. On a unit with forty residents and two aides, it is not clear what working it out was supposed to look like.
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.
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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.
The unit housed more than forty residents.
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.