Villa Manor Care Center
VILLA MANOR CARE CENTER in LAKEWOOD, CO — inspection on March 19, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
065092
Form Approved OMB
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
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
065092
Form Approved OMB
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