Villa Manor Care Center

F-F677: failure to provide activities of daily living for dependent residents.

Findings include:

I. Facility policy and procedure

The Staffing policy, revised 8/7/23, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, The facility maintains adequate staff on each shift to meet the residents' needs. The facility utilizes the facility assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met.

II. Resident and family interviews

Resident #1 was interviewed on 3/19/25 at 10:15 a.m. She said the facility did not have enough staff to care for her needs. She said when the facility was short staffed and had only two certified nurse aides (CNA) working, she did not receive her showers and incontinence care was not provided. She said it could take up to 45 minutes to receive incontinence care. She said she was supposed to receive her shower on Tuesday, Thursday, Saturday and Sunday.

Resident #2's representative was interviewed on 3/19/25 at 2:09 p.m. The representative said the Resident #2 was not receiving adequate showers the last few months. She said she had to call the facility to get staff to provide showers to the resident. She said she had to call multiple days in a row. She felt the facility did not have enough staff to complete the resident cares. She said she felt the resident had been receiving more showers in March 2025.

III. Facility assessment

The facility assessment, dated 11/20/24, was provided by the NHA on 3/19/25 at 10:44 a.m.

The facility assessment documented the care needs of 78 to 85 residents in the facility.

The facility assessment documented the direct care staffing information. The desired per patient day (PPD) for certified nurse aides (CNAs) was 2.26 hours. It documented the assignments were reviewed daily based

on resident needs and available staffing.

IV. Grievances

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 065092 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065092 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 The January 2025 to March 2025 grievances revealed the following:

Level of Harm - Minimal harm or A grievance dated 1/5/25 documented the CNA did not set up the residents meal tray or chop up the food. potential for actual harm The CNA was educated on assisting the residents with their meals

Residents Affected - Some A grievance dated 1/6/25 documented there was no restorative CNA for two weeks and no CNA for the day.

The facility stated the resident did receive her restorative services.

A grievance dated 1/23/25 and 1/30/25 documented the CNAs complained to the residents about being short staffed. The facility educated the CNAs to not discuss staffing issues with the residents.

A grievance dated 2/8/25 documented the resident had to call the front desk to request to get out of bed. The resident said it was a miscommunication with staff.

A grievance dated 3/5/25 documented the family was concerned with the resident not receiving timely care.

The facility educated the nursing staff on the timeliness of giving care to the residents.

A grievance dated 3/7/25 documented the CNA rushed her while providing care. The CNA was moved to a different assignment. The facility did not look into staffing issues.

V. Staff Interviews

CNA #1 was interviewed on 3/19/25 at 1:33 p.m. CNA #1 said the facility had been short on CNA staff for over a year. CNA #1 said sometimes the facility only had two CNAs to work the unit with 50 residents. She said the shortage prevented the CNAs from doing their assigned showers for the residents. She said in February 2025 she worked a shift by herself to care for 45 residents. She said this included two residents who required two person assistance with mechanical transfers, two residents with foley catheters, four residents with colostomy bags and one resident who required total assistance. She said when a resident was

a two person assistance and the facility was short staffed the resident was left in bed soiled. She said this happened because the CNA either did not have time or help to provide incontinence care to the resident or there were not two staff members to help. She said when she brought the staffing concerns to the management, she was told to just do what she could.

She said Resident #1 needed two staff members for bathing and toileting. She said when the CNA did not have another staff member to help, they had to take care of her alone. She said the day prior (3/18/25), a CNA worked alone for two hours,and cared for 24 residents alone. She said most of the nurses did not want to assist the residents with personal care.

CNA #2 was interviewed on 3/19/25 at 2:30 p.m. CNA #2 said the main floor census was 50 residents and there should be three to four CNAs scheduled. She said she wished the facility would use agency staff when

they were short staffed. She said the facility CNAs were unable to complete the resident cares. She said when the unit was short staffed, the CNA did not have time to complete scheduled showers. She said only two CNAs had been working the prior two days on the evening shift. She said the CNAs did the best they could to care for the residents, but there were times when incontinence care and oral care did not always get done. She said at times the restorative CNA was pulled to work the floor. She said the management did not help work the floor when they were short staffed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 065092 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065092 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 CNA #3 was interviewed on 3/19/25 at 2:35 p.m. CNA #3 said the facility did not have enough staff to complete their work. She said the unit was short staffed often. She said sometimes the CNAs were unable to Level of Harm - Minimal harm or provide scheduled showers, since the unit was short staffed. She said when the facility was short staffed the potential for actual harm CNAs had to rush the residents care. She said many times she had to stay late after her shift to finish her charting. She said the day shift was supposed to be staffed with four to five CNAs. She said when they only Residents Affected - Some had two CNAs to work the unit, scheduled showers did not get done. She said at times they were unable to provide incontinent care and would have to pass it on to the evening shift. She said when only two CNAs were working and a resident required a two person transfer, the one CNA would have to wait for the second CNA to be available to help with the transfer, which could take up to an hour.

CNA #4 was interviewed on 3/19/25 at 2:45 p.m. CNA #4 said the unit was usually staffed with two to three

CNAs. He said the shortage of CNAs had caused CNAs to not be able to provide the care the residents needed in a timely manner. He said the shortage would delay personal care and the CNAs would not be able to provide the scheduled showers. He said when only two CNAs were working the unit the CNA would try and find the nurse to assist. However, he said that could take 20 to 30 minutes. He said in regard to incontinence care, the CNAs would have to triage the residents who had a bowel movement to be changed over residents who were wet. He said when the CNAs would take their concerns to the management, they were told to work it out.

Licensed practical nurse (LPN) #1 was interviewed on 3/19/25 at 2:50 p.m. LPN #1 said the facility had been short on CNAs for a while. She said frequently there were only two CNAs working the unit for forty some residents. She said she would try to help the CNAs but had physical limitations. She said when the unit was short staffed it delayed resident care and showers. She said at times a resident who required two person assistant would have to wait until the next CNA to come on shift to assist with changing the resident. She said the residents would have to stay wet or soiled until a second CNA was available to help.

The DON was interviewed on 3/19/25 at 3:37 p.m. The DON said she did not know why showers were not being completed, but thought it may be a documentation error. She said she was super confident about the facility staffing. She said if a CNA called off for their shift, managers would help with transfers and showers.

She said the facility would utilize agency staff if needed. She said she was not aware there was an issue with showers and ADL care. She believed the residents were receiving care. She said the facility met the minimum state staffing regulation.

The regional vice president (RVP) was interviewed on 3/19/25 at 3:55 p.m. The RVP said the NHA had only been working at the facility for three days. She said the facility did not have any concerns with staffing. She said the facility had experienced some staff turnover and had hired some new staff. She said missed showers were related to documentation issues. She said the DON needed to provide education related to documentation and how the staff were managing their time. She said staffing was the facility's main focus and had increased the CNA pay. She said she worried about the perception of the families and staff related to staffing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 065092

F-F725: failure to have adequate nurse staffing.

Findings include:

I. Facility policy and procedure

The Activities Of Daily Living (ADLs) policy, revised 2/12/24, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, The resident will receive assistance as needed to complete ADLs. A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene.

II. Resident #1

A. Resident status

Resident #1, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), age-related osteoporosis, neuromuscular dysfunction of the bladder (urinary incontinence), muscle weakness and irritable bowel syndrome.

The 2/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 15 out of 15. She had no behaviors and did not reject care. She had impairment to one side of her upper and lower extremities. She used a motorized wheelchair and was dependent on staff for bathing and toileting hygiene. She was occasionally incontinent of bowel and bladder.

B. Resident interview

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 8 065092 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065092 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Resident #1 was interviewed on 3/19/25 at 10:15 a.m. She said the facility did not have enough staff to care for her needs. She said when the facility had only two certified nurse aides (CNA) working, showers were not Level of Harm - Minimal harm or provided. She said she was supposed to receive her showers on Tuesday, Thursday, Saturday and Sunday. potential for actual harm C. Resident representative interview Residents Affected - Some Resident #2's representative was interviewed on 3/19/25 at 2:09 p.m. The representative said Resident #2 was not receiving adequate showers the last few months. She said she had to call the facility to get staff to shower the resident. She said she felt the resident had been receiving more showers in March 2025.

D. Record review

The ADL care plan, revised on 8/29/23, revealed Resident #1 had an ADL self care deficit related to weakness, impaired range of motion, occasional incontinence, diagnosis of MS, depression, left sided weakness and contracture (restricts normal movement) to the left hand and left elbow. Interventions included providing total staff assistance with bathing four times a week with a female care giver.

Review of the January 2025 through March 2025 shower logs revealed the following:

The January 2025 (1/19/25 to 1/31/25) shower documentation revealed Resident #1 was provided bathing

on one of six opportunities.

The February 2025 (2/1/25 to 2/28/25) shower documentation revealed Resident #1 was provided bathing on two of 16 opportunities.

The March 2025 (3/1/25 to 3/19/25) shower documentation revealed Resident #1 was provided bathing on three of 11 opportunities.

III. Resident #2

A. Resident status

Resident #1, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included diabetes, dementia, cancer and liver failure.

The 12/20/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. She required supervision assistance with toileting and dressing. She required partial assistance with bathing.

B. Record review

The ADL care plan, revised on 12/16/24, revealed Resident #2 had an ADL self care deficit related to dementia, impaired balance, limited mobility and muscle weakness. Interventions included assisting the resident with ADLs as needed and praising the resident for all efforts of self care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 8 065092 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065092 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 -Review of the comprehensive care plan did not reveal documentation that indicated the resident's shower preferences and assistance needed. Level of Harm - Minimal harm or potential for actual harm Review of the January 2025 through March 2025 shower logs revealed the following:

Residents Affected - Some The January 2025 (1/19/25 to 1/31/25) shower documentation revealed Resident #1 was provided bathing

on one of four opportunities.

The February 2025 (2/1/25 to 2/28/25) shower documentation revealed Resident #1 was provided bathing on two of eight opportunities.

The March 2025 (3/1/25 to 3/19/25) shower documentation revealed Resident #1 was provided bathing on two of five opportunities.

IV. Resident #3

A. Resident status

Resident #3, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included dementia, anxiety and kidney disease.

The 2/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required maximal assistance with toileting, dressing and bathing.

B. Record review

The ADL care plan, revised on 8/5/24, revealed Resident #3 had an ADL self care deficit related to weakness, decreased mobility, usage of high high risk medications, obesity and depression. Interventions included assisting the resident with ADLs as needed and providing the resident showers two times a week

on Tuesday and Saturday.

Review of the January 2025 through March 2025 shower logs revealed the following:

The January 2025 (1/19/25 to 1/31/25) shower documentation revealed Resident #1 was provided no bathing out of three opportunities.

The February 2025 (2/1/25 to 2/28/25) shower documentation revealed Resident #1 was provided no bathing out of seven opportunities.

The March 2025 (3/1/25 to 3/19/25) shower documentation revealed Resident #1 was provided bathing on five of six opportunities.

V. Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 065092 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065092 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 CNA #1 was interviewed on 3/19/25 at 1:33 p.m. CNA #1 said the facility had been short on CNA staff for over a year. CNA #1 said sometimes the facility only had two CNAs to work the unit with 50 residents. She Level of Harm - Minimal harm or said the shortage prevented the CNAs from doing their assigned showers for the residents. She said in potential for actual harm February 2025 she worked a shift by herself to care for 45 residents. She said two residents required two person assistance with mechanical transfers She said when she brought the staffing concerns to the Residents Affected - Some management, she was told to just do what she could. She said Resident #1 needed two staff members for bathing. She said when the CNA did not have another staff member to help, they had to take care of her alone. She said the day prior (3/18/25), a CNA worked alone for two hours, and cared for 24 residents alone.

She said most of the nurses did not want to assist the residents with personal care.

CNA #2 was interviewed on 3/19/25 at 2:30 p.m. CNA #2 said the main floor census was 50 residents and there should be three to four CNAs scheduled. She said she wished the facility would use agency staff when

they were short staffed. She said the facility CNAs were unable to complete the resident cares. She said when the unit was short staffed, the CNA did not have time to complete the scheduled showers. She said only two CNAs had been working the prior two days on the evening shift. She said the CNAs did the best

they could to care for the residents, but there were times when incontinence care and oral care did not always get done. She said at times the restorative CNA was pulled to work the floor. She said the management did not help work the floor when they were short staffed.

CNA #3 was interviewed on 3/19/25 at 2:35 p.m. CNA #3 said the facility did not have enough staff to complete their work. She said the unit was short staffed often. She said sometimes the CNAs were unable to provide the scheduled showers, since the unit was short staffed. She said when they only had two CNAs staffed to work the unit, scheduled showers did not get done. CNA #4 was interviewed on 3/19/25 at 2:45 p. m. CNA #4 said the unit was usually staffed with two to three CNAs. He said the shortage of CNAs had caused the CNAs to not be able to provide the care the residents needed in a timely manner. He said the shortage would delay personal care and the CNAs would not be able to provide the scheduled showers. He said when only two CNAs were working the unit, the CNAs would try and find the nurse to assist. However,

he said that could take 20 to 30 minutes. He said when the CNAs would take their concerns to the management, they were told to work it out.

Licensed practical nurse (LPN) #1 was interviewed on 3/19/25 at 2:50 p.m. LPN #1 said the facility had been short on CNAs for a while. She said frequently there were only two CNAs working the unit for forty some residents. She said she would try to help the CNAs but had physical limitations. She said when the unit was short staffed it delayed resident care and showers. She said at times a resident who was a two person assistant would have to wait until the next CNA to come on shift to assist with changing the resident. She said the residents would have to stay wet or soiled until a second CNA was available to help.

The DON was interviewed on 3/19/25 at 3:37 p.m. The DON said she did not know why showers were not being completed, but thought it may be a documentation error. She said she was super confident about the facility staffing. She said if a CNA called off for their shift, managers would help with transfers and showers.

She said the facility would utilize agency staff if needed. She said she was not aware there was an issue with residents not getting their showers. She thought the residents were getting their showers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 065092 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065092 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 The regional vice president (RVP) was interviewed on 3/19/25 at 3:55 p.m. She said missed showers were related to documentation issues. She said the DON needed to provide education related to documentation Level of Harm - Minimal harm or and how they were managing their time. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 065092 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065092 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 40960

Residents Affected - Some Based on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner.

Specifically, the facility failed to ensure residents received their showers as scheduled and incontinence care

in a timely manner for residents dependent on staff for their care.

Cross reference