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F0565
E

Failure to Resolve Resident Council Grievances Regarding Staffing and Shower Conditions

Westminster, Colorado Survey Completed on 05-01-2025

Penalty

Fine: $32,860
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly resolve grievances raised by the resident council regarding insufficient floor staff, long call light wait times, and lack of hot water for showers. Multiple residents, including the resident council president and vice president, reported repeated issues during interviews and resident council meetings. Residents described frequent staff shortages, especially on evenings and weekends, resulting in long waits for assistance with activities of daily living (ADLs), pain medication, and showers. Several residents also noted that agency staff were unfamiliar with their care needs, and that the facility no longer felt like a home. Resident council meeting minutes over several months documented ongoing concerns about missed or delayed showers, cold water in the shower rooms, and inadequate CNA coverage, particularly on weekends. Despite these concerns being raised repeatedly, the meeting minutes did not indicate specific actions taken to ensure residents received scheduled showers or that the hot water issue was resolved. The facility leadership acknowledged the problems and stated that efforts were being made to hire more staff and address the water issue, but the same concerns persisted in subsequent meetings. Call light observation logs revealed that monitoring was not conducted during evening, night, or weekend shifts, and documented wait times ranged from one to over 50 minutes. Staff interviews confirmed that staffing shortages led to delayed responses to call lights and unmet resident care needs. Maintenance staff were only recently made aware of the hot water issue, despite residents having reported it for several months. The DON and NHA both acknowledged ongoing staffing challenges and the reliance on agency staff, which contributed to the unresolved grievances.

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