Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor View Care Center, Llc during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, osteoarthritis, severe cognitive impairment, and a history of repeated falls was care planned as a high fall risk with interventions including anticipating needs and ensuring use of appropriate non-skid footwear during ambulation. On one occasion, the resident was found on the floor in another resident’s room wearing regular socks, with her shoes neatly placed on the bed, indicating the non-skid footwear intervention was not in use. Staff interviews showed inconsistent awareness of the resident’s fall risk status and assumptions about the resident’s whereabouts, while documentation noted that the resident, previously independently ambulatory, was unable to walk after the fall, had increased confusion, and complained of pain. The resident was later hospitalized and diagnosed with a subdural hematoma and a left hip fracture requiring surgery, and the deficiency centers on the failure to follow the fall care plan and provide adequate supervision to prevent this accident.
A resident with severe dementia and dysphagia experienced significant weight loss due to the facility's failure to provide consistent meal assistance and accurately document food intake. Despite being on restorative dining services, the resident often consumed less than 25% of meals, while records inaccurately showed higher intake. The facility's inaction and inconsistent care led to severe weight loss, highlighting a deficiency in meeting the resident's nutritional needs.
The facility failed to provide timely meal service and treat residents with dignity in the Aspen and Pine Ridge dining rooms. Residents experienced significant delays in receiving meals, and staff did not engage respectfully, often failing to address residents by their preferred names. In the main dining room, a CNA was observed using a cell phone instead of engaging with a resident during meal service. Staff interviews revealed a lack of clarity in meal tray delivery and dining room assignments.
The facility failed to honor the preferences of three residents regarding showers and catheter assistance. A resident did not receive showers as per her preference, with the care plan not reflecting her current needs. Another resident experienced inconsistent shower schedules due to staffing changes, and a third resident faced issues with shower schedules and catheter assistance for church. The facility's reliance on agency staff unfamiliar with residents' preferences contributed to these deficiencies.
The facility failed to promptly resolve grievances regarding agency staff competency for several residents. Issues included inconsiderate care, missed showers, and lack of awareness of personal preferences. Staff interviews revealed inadequate communication and documentation of residents' routines, contributing to dissatisfaction.
A facility reported a medication error rate of 16.1%, exceeding the acceptable threshold. An RN delayed administering Lactaid and missed a nasal spray for a resident due to unfamiliarity with preferences. An LPN administered three medications late, citing workload. The DON was unaware of these issues, indicating systemic problems with medication timing.
The facility failed to employ a qualified infection preventionist (IP) with specialized training in infection prevention and control, as required by their policy. The Director of Nursing (DON) confirmed that the facility did not have a designated IP and was recruiting for the position. In the interim, the DON and unit nurse managers shared the IP duties without the necessary specialized education.
The facility failed to provide appropriate respiratory care for two residents. One resident's CPAP machine was broken and not addressed despite physician recommendations, while another resident was frequently observed without her nasal cannula properly in place. The facility's policies did not adequately cover CPAP use, and care plans lacked specific interventions to ensure proper oxygen therapy.
The facility did not post daily nurse staffing information as required, with observations showing outdated data. The DON confirmed the need for daily updates and identified the scheduler as responsible. The scheduler had delegated the task to her assistant and was unaware of the lapse.
Failure to Follow Fall Care Plan and Ensure Appropriate Footwear Resulting in Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at high risk for falls received adequate supervision and appropriate footwear as care planned, resulting in a fall with major injury. The resident was an older adult with osteoarthritis, dementia, Alzheimer’s disease, repeated falls, severe cognitive impairment (BIMS score 3/15), and a documented history of falls. The resident’s fall care plan, initiated months earlier and revised prior to the incident, identified her as a high fall risk related to deconditioning, gait and balance problems, incontinence, poor communication and comprehension, unawareness of safety needs, and prior falls. Among the listed interventions was the requirement to anticipate and meet her needs and to encourage the resident to wear appropriate footwear/non-skid socks when ambulating or mobilizing in a wheelchair. On the date of the incident, the resident sustained an unwitnessed fall and was later found lying on the floor of another resident’s room. Nursing documentation and the IDT note recorded that the resident’s shoes or slippers were on the bed in that room, positioned neatly, and that she was wearing regular socks rather than the care-planned non-skid/anti-slip socks at the time of the fall. Staff interviews corroborated that the resident did not have non-skid socks on; a CNA specifically recalled the resident wearing regular black socks. The care plan intervention requiring non-skid socks had been in place since 7/19/23, but the resident was not wearing them when she was discovered on the floor. The IDT note identified the root cause of the fall as a change in condition with altered mental status, but the documentation and DON interview confirmed that the anti-slip sock intervention was not in use at the time of the fall. Following the fall, multiple staff documented that the resident was unable to walk and required a wheelchair, which was a change from her prior status of independent ambulation without assistive devices. Nursing notes described the resident complaining of pain in her left arm and left leg, difficulty standing on her left leg, and increased confusion compared to baseline. Neurological checks were initiated, and a STAT X-ray was ordered and read as negative, but the resident continued to show pain, difficulty bearing weight, and altered mentation. Two days after the fall, due to ongoing increased confusion, pain, and inability to walk, the resident was sent to the hospital, where she was diagnosed with a subdural hematoma and a closed left hip fracture requiring surgical repair. The deficiency centers on the facility’s failure to follow the established fall care plan intervention for appropriate non-skid footwear and to provide adequate supervision to prevent accidents for this high fall risk resident. Staff interviews further highlighted gaps in awareness and implementation of fall risk interventions. One CNA stated that the resident was not a fall risk and was independent with ambulation, which conflicted with the care plan identifying her as a high fall risk with specific fall interventions. Another CNA described assuming the resident had gone on an outing when she did not see her on the secured unit and only began searching after the nurse could not confirm the resident’s whereabouts, at which point the resident was found on the floor in another room. The memory care director reported that the resident often wandered into that other resident’s room and was found there on her left side, complaining of pain when staff attempted to assist her. These observations and statements demonstrate that the resident’s known fall risk status and care-planned interventions, including appropriate footwear and supervision, were not consistently recognized or implemented at the time of the fall.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to meet their nutritional needs, resulting in severe weight loss. The resident, who was admitted with severe dementia, hypothyroidism, depression, and dysphagia, experienced a significant decline in weight over several months. Despite being placed on restorative dining services, the resident did not consistently receive the required assistance during meals, leading to inadequate food and fluid intake. Observations during the survey revealed that the resident often ate less than 25% of their meals, yet meal intake documentation inaccurately recorded higher consumption rates. The facility's policy required residents with significant weight changes to be assessed by an interdisciplinary team and have interventions implemented to minimize further weight loss. However, the resident's weight continued to decline, with a 9.1% loss over three months. The facility's failure to provide timely and consistent meal assistance, offer alternatives of equal nutritional value, and accurately record food intake contributed to the resident's severe weight loss. Interviews with staff indicated that the resident's mood and confusion affected their ability to eat, and staff did not consistently provide the necessary support or document the resident's actual food intake accurately. The resident's care plan included monitoring weights, documenting and reporting any signs of swallowing difficulties, and offering food preferences. Despite these interventions, the resident's weight loss persisted, and the facility did not effectively address the resident's nutritional needs. The resident's family was involved in discussions about food preferences, but the facility did not document the consumption of family-provided snacks. The facility's inaction and inconsistent care led to the resident's severe weight loss, highlighting a deficiency in meeting the resident's nutritional needs.
Failure to Ensure Timely and Respectful Meal Service
Penalty
Summary
The facility failed to ensure residents were treated with dignity in two out of four dining rooms, specifically in the Aspen and Pine Ridge dining rooms. Observations revealed that meal service was not provided in a timely manner, with some residents receiving their meals 40 to 50 minutes after others at the same table. Additionally, staff failed to engage with residents respectfully, often not addressing them by their preferred names and discussing personal care in front of other residents. In the Aspen dining room, multiple instances were observed where residents waited excessively for their meals. On several occasions, meal trays intended for residents eating in their rooms were delivered before those for residents in the dining room, causing significant delays. Staff were also observed not sitting down while assisting residents with meals, failing to engage with them, and not addressing them by name. Similar issues were noted in the Pine Ridge dining room, where residents were left waiting for extended periods before receiving their meals, and staff did not engage with them appropriately. The main dining room also exhibited deficiencies, with a CNA observed using a cell phone and not engaging with a resident during meal service. Interviews with staff revealed a lack of clarity in dining room assignments and meal tray delivery systems, contributing to the delays and lack of engagement. The facility's policies on dignity and meal assistance were not adequately followed, leading to the observed deficiencies.
Failure to Honor Resident Preferences for Showers and Catheter Assistance
Penalty
Summary
The facility failed to honor the preferences of three residents regarding their activities of daily living, specifically in providing showers and assisting with a leg catheter bag. Resident #56, who was cognitively intact and required substantial assistance, reported not receiving showers as per her preference of twice a week. The care plan did not reflect her current preferences, and the shower logs indicated she received only one shower in a month, with no documentation of refusals. Resident #6, also cognitively intact and requiring substantial assistance, experienced inconsistent shower schedules. She preferred showers twice a week, but the facility's elimination of a dedicated shower aide position and reliance on agency staff led to missed showers. The care plan did not address her current preferences, and the shower logs showed she received only five out of nine scheduled showers, with no documentation of refusals. Resident #65, who was cognitively intact and required moderate assistance, faced similar issues with inconsistent shower schedules and a lack of assistance with his leg catheter bag on Sundays for church. His care plan did not reflect his shower preferences or the need for a leg catheter bag. The facility's reliance on agency staff, who were unfamiliar with residents' preferences, contributed to these deficiencies, as confirmed by staff interviews.
Failure to Address Grievances Related to Agency Staff Competency
Penalty
Summary
The facility failed to ensure prompt resolution of grievances related to the competency of agency staff for six residents. The grievance policy required that grievances be responded to promptly and in written form, with findings and corrective actions communicated within 10 working days. However, residents reported that their grievances, particularly regarding agency staff's lack of awareness of their preferences and routines, were not addressed in a timely or satisfactory manner. Residents expressed dissatisfaction with the inconsistency in care provided by agency staff. One resident reported that agency staff were inconsiderate and did not accommodate her preference for taking medication with hot water. Another resident experienced issues with shower schedules and catheter bag changes, which were not adhered to by agency staff, causing frustration and disruption to his routine. Other residents also reported missed showers, lack of awareness of personal preferences, and disturbances during the night due to staff actions. Interviews with staff revealed that there was a lack of communication and documentation regarding residents' preferences, which contributed to the grievances. Agency staff were not adequately informed about residents' routines and preferences, leading to missed care and dissatisfaction. The facility's records, such as resident council minutes, indicated that concerns were marked as resolved without documentation of how they were addressed or if residents were satisfied with the outcomes.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported error rate of 16.1%, equating to five errors out of 31 opportunities. The errors were identified through observations, record reviews, and staff interviews. The facility's policy mandates that medications be administered accurately, safely, timely, and in compliance with physician orders. However, deviations from these standards were observed, leading to the noted deficiencies. One incident involved a registered nurse (RN) who was observed administering medications to a resident. The RN was unable to locate the correct dose of Lactaid medication and delayed its administration by over two hours. Additionally, the RN failed to administer the resident's prescribed nasal spray. The RN, an agency nurse on his first day, faced challenges due to unfamiliarity with resident preferences, which contributed to the errors. Another incident involved a licensed practical nurse (LPN) who administered three medications late to a resident. The medications were color-coded red on the medication administration record, indicating they were overdue. The LPN cited a high volume of medications to administer as a reason for the delay. Interviews with staff, including the Director of Nursing (DON), revealed a lack of awareness regarding the timeliness of medication administration, highlighting systemic issues in adhering to scheduled times.
Facility Lacks Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified infection preventionist (IP) who had completed specialized training in infection prevention and control, as required by their Infection Control and Surveillance policy. The policy, dated 7/28/23, mandates that an infection prevention and control program (IPCP) be established and maintained to ensure a safe, sanitary, and comfortable environment, preventing the development and transmission of communicable diseases and infections. The IPCP is supposed to be coordinated and overseen by an IP specialist. Upon review, it was found that the facility did not have a designated IP and was in the process of recruiting for the position. The Director of Nursing (DON) confirmed that the facility lacked a qualified IP and that she, along with the unit nurse managers, were sharing the duties and responsibilities of the IP position without having completed the required specialized education for the role.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. Resident #56, who was diagnosed with acute and chronic respiratory failure, COPD, and dependence on supplemental oxygen, had a CPAP machine that was not functioning properly. Despite the resident's report that the machine was broken and the physician's recommendation for service or replacement, the facility did not document any attempts to address the issue. Staff members, including CNAs and nurses, were unaware of the resident's need for the CPAP machine, and there was no physician's order for its use. Resident #21, who had severe cognitive impairment and required oxygen therapy, was observed multiple times without her nasal cannula properly in place. The resident's care plan did not include interventions to ensure she was wearing her nasal cannula as ordered. Despite the resident's oxygen saturations being documented as within normal limits, there were instances where the nasal cannula was not in place, and staff interviews revealed that the resident could not replace it herself. The facility's failure to ensure the resident was consistently receiving oxygen as ordered contributed to the deficiency. The facility's policies and procedures for oxygen administration did not adequately address the use of CPAP or BiPAP machines, contributing to the oversight in Resident #56's care. Additionally, the lack of specific interventions in Resident #21's care plan to ensure proper oxygen therapy further highlighted the facility's failure to adhere to professional standards of practice in respiratory care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required, resulting in a deficiency. Observations on two consecutive days revealed that the posted staffing information was outdated, showing data from four days prior. During an interview, the Director of Nursing (DON) acknowledged that the information should be updated daily and identified the scheduler as responsible for this task. The scheduler admitted to delegating the responsibility to her assistant and was unaware of why the information had not been updated since the specified date.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Arvada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arvada Care And Rehabilitation Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Westminster | 1.8 mi | ★★★★★ | 1 | 0 |
| Park Forest Care Center Llc | 2.1 mi | ★★★★★ | 4 | 0 |
| Village Care And Rehabilitation Center, The | 2.6 mi | ★★★★★ | 0 | 0 |
| Clear Creek Care Center | 2.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.