Frasier Meadows Health Care Center

In the surveyor’s words

From the most serious findings on record at Frasier Meadows Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 16, 2024

  Based on observations, record review and interviews the facility failed to ensure one (#31) of three residents reviewed for pressure-related skin conditions out of 19 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #31, who was at risk for developing pressure injuries due to a recent surgery to replace his left hip joint, was admitted to the facility on [DATE]. According to the facility's assessment of the resident's skin on 3/8/24, the resident was admitted without any pressure injuries. […]

• Actual harm, isolatedF689Jan 10, 2023

  Based on observations, record review and interviews, the facility failed to implement timely interventions for falls and for falls with injury for three (#5, #26 and #54) of six out of 17 sample residents reviewed. Resident #5 had diagnoses of dementia, normal pressure hydrocephalus (a condition in which fluid accumulates in the brain) and history of repeated falls prior to admission 6/30/22. The facility failed to develop a person centered plan of care to promote safety and prevent repeated falls with injury. Resident #5 had falls on 8/15/22, 9/7/22 and 12/29/22, the resident suffered a skin tear, bruising and a head laceration (see record review). On 9/7/22 Resident #5 suffered a laceration to her head she was hospitalized and received five staples to her head. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and one out of one satellite kitchen.Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated, and discarded within appropriate good-through timeframes.Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 6/9/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. […]

• No harm, potential for more than minimal, patternF847Jun 4, 2026

  Based on record review and interview, the facility failed to ensure residents' rights regarding arbitration were protected for three (#28, #36 and #39) of three residents reviewed for arbitration out of a sample size of 27. Specifically, the facility failed to inform the Resident #28, Resident #36, Resident #39 or their representative that they had the right to rescind or terminate the agreement within 30 calendar days of signing.Findings include:I. Facility admission agreement and policyThe admission Agreement and Binding Arbitration Agreement, revised January 2025, was provided by the nursing home administrator (NHA) on 6/1/26 at 11:52 a.m. Review of the agreement revealed it did not inform the resident or their representative of their right to revoke the agreement. […]

• No harm, potential for more than minimal, patternF947Jun 4, 2026

  Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training to ensure continued competence for five of five CNAs reviewed.Specifically, the facility failed to have a system in place to ensure CNAs including CNA #5, CNA #8, CNA #9, CNA #10 and CNA #11 received annual dementia training.Findings include:I. Training record review reviewA review of CNA training was completed on 6/4/26 at 10:10 a.m. […]