Aviva at Fitzsimons

In the surveyor’s words

From the most serious findings on record at Aviva at Fitzsimons, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 26, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 10 sample residents remained free from accidents.Resident #1 was admitted to the facility on [DATE] with diagnoses of history of falling, a fracture of the left ilium (upper part of the pelvis), atrial fibrillation (AFIB), hypertension (high blood pressure) and dementia. Resident #1 had severe cognitive impairments and required maximum assistance from staff. On 8/13/25 at approximately 4:30 p.m. Resident #1 was seated at the nurses' station where he sustained an unwitnessed fall. Resident #1 was assessed by a registered nurse (RN) and was assessed to have no injuries. After the fall, the staff assisted Resident #1 in his wheelchair back to the nurses' station. […]

• Actual harm, isolatedF684Jul 31, 2023

  Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (#52) of three residents reviewed out of 52 sample residents. Resident #52 was admitted to the facility after being hospitalized for worsening congestive heart failure. The resident had a history of chronic congestive heart failure and resistance to oral antibiotics. During the hospital stay just prior to the resident's admission the resident was treated for severe edema/ water retention as evidenced by a rapid significant weight gain and swelling in both lower extremities and muscle weakness and fatigue. […]

• Actual harm, isolatedF689Apr 6, 2023

  Based on record review, observations and interviews, the facility failed to ensure three (#6, #2 and #9) of three residents received adequate supervision to prevent accidents out of 16 sample residents reviewed. Specifically, the facility failed to ensure Resident #6, who had a history of falls and was assessed to be a high fall risk upon admission, received the care and services indicated in her comprehensive plan of care. The facility failed to ensure Resident #6's call light was answered timely, which was an intervention on her care plan, to prevent the resident from getting up without assistance. On 1/30/23, Resident #6 reported she pushed her call light and waited for 30 minutes to be assisted to the bathroom. […]

• No harm, potential for more than minimal, widespreadF851Oct 8, 2024

  Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include: I. Record review The PBJ staffing report for quarter three (4/1/24 to 6/30/24) showed the following triggered areas: -Excessive low weekend staffing; and, -One star rating. The trigger for low weekend staffing triggered the facility's one star rating. -However, review of the facility's April 2024 to June 2024 staff time cards revealed the facility did not have low weekend staffing. II. Staff interview The nursing home administrator (NHA) was interviewed on 10/7/24 at 2:45 p.m. […]

• No harm, potential for more than minimal, widespreadF842Jul 31, 2023

  Based on record review and interviews, the facility failed to keep confidential resident-identifiable personal information and medical treatments for 27 of 27 residents; and to ensure medical records were complete and accurately documented medical status and response to nursing/medical care and treatment in keeping with accepted standards of practice for a sample of two of four residents reviewed. Specifically, the facility failed to: -Keep confidential information specifically protected health information (PHI) out of view of other residents and visitors for 27 of 27 residents on the unit; and, -Ensure Resident #47's medical record contained accurate and complete documentation regarding the resident's restorative management plan; restorative services provided; and the resident's… […]