Wheatridge Park Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 4, 2024

  The facility reported a census of 41 residents and identified 11 cognitive impaired females. The sample included three residents reviewed for abuse. Based on interviews, observations, and record review, the facility failed to provide a safe environment when staff did not provide adequate supervision to prevent resident-to-resident sexual abuse. On 12/10/23 staff found cognitively intact, independent Resident (R )1 kissing R2, a resident with severe cognitive impairment who lacked the ability to consent. Staff reported R1 had his hand inside of R2's shirt, and R2 had her hand inside of R1's pants. The staff separated the residents. This deficient practiced placed R2 in immediate jeopardy. […]

• Actual harm, isolatedF686Sep 16, 2024

  The facility identified a census of 40 residents, with 12 residents sampled, and one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide a pressure reducing device on the bed to prevent a pressure injury for Resident (R) 2. On 07/11/24 the facility noted R2's previous pressure injuries were all closed. On 07/12/24, R2 was moved to a different room and the facility failed to move his air mattress for his bed to the new room. […]

• Actual harm, isolatedF689Sep 16, 2024

  The facility identified a census of 40 residents, which included 12 residents sampled and three reviewed for accidents and accident hazards. Based on interviews, observations, and record review, the facility failed to provide an environment free of accident hazards for the residents of the facility when the facility failed to properly store chemicals in an unlocked cabinet in an unlocked room and when the facility stored chemicals along a rail in the hallway. Additionally, the facility failed to ensure R26, who was identified by the facility as confused and independently mobile with aggressive and wandering behaviors, remained free of accident hazards when R26 put scissors in his pocket and wandered inside the facility. […]

• Actual harm, isolatedF689Nov 30, 2021

  The facility reported a census of 44 residents, with five sampled for falls. Based on observation, interview, and record review the facility failed to thoroughly complete fall investigations for each resident to include identification of causal factors related to the fall and/or a new fall prevention intervention to prevent future falls after each fall experienced by Resident (R)2, R4, and R5. Due to these failures, R2 fell multiple times, endured a subacute subdural hematoma (type of brain bleed that results from a tear in a blood vessel in the brain, usually from trauma), fell again later the same day, and staff found the resident unresponsive. […]

• No harm, potential for more than minimal, widespreadF730Sep 16, 2024

  The facility reported a census of 40 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for five Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. The facility identified five CNAs employed over 12 the month period. Findings included: - Review of employee files on 09/12/24 at 2:00 PM revealed a lack of performance evaluations signed by management for five of five Certified Nurse's Aides (CNAs), that had been employed over one year, that included Certified Nurse's Aide CNA P, CNA Q, CNA R, CNA S and CNA T. […]