Wheatridge Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760May 10, 2023

  Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of five sample residents. On 4/29/23 at approximately 7:30 p.m. Resident #1 was administered Methadone (opioid analgesic) medication by agency licensed practical nurse (LPN) #1. The medication was not ordered for her. The medication was administered to the wrong resident, at the wrong time, by the wrong route to Resident #1. On 4/30/23 at approximately 12:30 a.m., Resident #1 was found to be unresponsive with oxygen saturation at 36% (with her normal saturation 95% or higher); emergency medical services were called and the resident was sent to the emergency department and treated for opioid overdose. […]

• Actual harm, isolatedF689Jun 12, 2025

  Based on record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured adequate supervision was provided for one (#18) of five residents reviewed out of 32 sample residents. Resident #18, who was at risk for falls related to weakness, multiple sclerosis (an autoimmune disease that affects the central nervous system) and a history of falls, was admitted to the facility on [DATE] for a long-term care stay due to the progressive nature of her illness. […]

• No harm, potential for more than minimal, widespreadF882Jun 12, 2025

  Based on observations and interviews, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to maintain an onsite and/or at least part-time infection control preventionist to properly assess, develop, implement, monitor, and manage the infection prevention and control program. Findings include: A. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was provided by the regional clinical resource (RCR) on 6/16/25 at 3:56 p.m. […]

• No harm, potential for more than minimal, widespreadF812Oct 19, 2023

  Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the kitchen, dish room and the dry storage room were identified and corrected in a timely manner. Findings include: I. Facility policies and procedures The Maintenance Service policy, revised December 2009, was provided by the director of clinical services (DCS) on 10/19/23 at 9:32 a.m. The policy revealed maintenance services should be provided to all areas of the building, grounds and equipment. […]

• No harm, potential for more than minimal, widespreadF814Oct 19, 2023

  Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for one of one dumpsters. Specifically, the facility failed to contain garbage and refuse within the dumpster. Findings include: I. Facility policy and procedures The Food Related Garbage and Refuse Disposal policy, revised October 2017, was provided by the director of clinical services (DCS) on 10/17/23 at 1:36 p.m. The policy revealed garbage and refuse containing food wastes would be stored in a manner that was inaccessible to pests. Storage areas would be kept clean at all times and should not constitute a nuisance. Outside dumpsters provided by garbage pickup services would be kept closed and free of surrounding litter. II. Observations On 10/16/23 at 9:50 a.m. and 12:46 p.m. […]