Villa Manor Care Center
VILLA MANOR CARE CENTER in LAKEWOOD, CO — inspection on March 19, 2025.
Found 4 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
and there should be three to four CNAs scheduled.
She said she wished the facility would use agency
showers.
She said only two CNAs had been working the prior two days on the evening shift.
She said
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.
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 and how they were managing their time.
065092 03/19/2025
Villa Manor Care Center 7950 W Mississippi Ave Lakewood, CO 80226
CNAs.
She said when they only had two CNAs to work the unit, scheduled showers did not get done.
transfer, the one CNA would have to wait for the second CNA to be available to help with the transfer,
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.
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.