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 Life Care Center Of Littleton during CMS and state inspections, most recent first.
A facility failed to provide adequate supervision and person-centered fall interventions for three residents, resulting in multiple falls and significant injuries. One resident with a history of falls and fractures did not have her care plan updated with specific interventions, leading to several falls with major injuries. Another resident experienced falls without new interventions being added to her care plan, and a third resident sustained a wrist fracture without specific fall prevention measures being implemented.
The facility failed to maintain sanitary conditions in food preparation and storage. A cook used a single glove for multiple tasks without changing it, violating food safety protocols. Expired food items were found in nourishment room refrigerators, despite policies requiring regular checks. The dietary manager and consultant acknowledged these issues during interviews.
The facility failed to maintain an effective infection control program, as evidenced by improper disinfection of high-touch areas and inadequate catheter care practices. Observations showed a housekeeper did not disinfect key surfaces in residents' rooms, and a CNA performed Foley catheter care without changing gloves or performing hand hygiene. These actions did not align with the facility's policies, potentially compromising resident safety.
A resident's preferences for therapy scheduling were not honored, leading to anxiety and pain management issues. Despite being cognitively intact and expressing a desire to know her therapy schedule, the facility failed to assess or document her preferences. Staff interviews revealed a lack of communication and adherence to procedures, resulting in a deficiency in resident rights.
A facility failed to follow PASRR Level II recommendations for a resident with schizoaffective disorder, as the resident had not been seen by a psychiatric provider since early 2024. Staff interviews revealed a lack of awareness and documentation regarding the need for psychiatric follow-up, despite the resident's active delusions and hallucinations.
A resident with a left hand contracture did not receive appropriate care as the facility failed to include the use of a navy blue hand brace in the restorative program and comprehensive care plan. The resident wore the brace inconsistently, and there was no documented schedule or physician's order for its use. Staff were unaware of the specifics regarding the brace's application, and the director of nursing acknowledged the oversight.
A resident with an indwelling catheter did not have a physician's order for routine care, maintenance, or monitoring, leading to inappropriate care. Despite the comprehensive care plan noting the catheter's necessity, there was no order for flushing the catheter, which was performed by a nurse when it leaked. Staff interviews revealed confusion about protocol adherence, and the DON acknowledged the admitting nurse's responsibility to obtain necessary orders, which was not fulfilled.
A facility failed to administer a resident's tube feeding as ordered and did not label feeding containers properly. The resident, with multiple health issues including dysphagia and quadriplegia, was found with an unlabeled feeding formula and incorrect water flush rate. Staff interviews confirmed the importance of following physician orders and labeling to prevent errors.
A resident in an LTC facility had a grab bar/bed rail installed without proper assessment for entrapment risks or informed consent. The facility did not document alternatives or conduct routine maintenance checks. Staff interviews revealed a lack of communication and documentation regarding the installation and use of the grab bar/bed rail, contrary to facility policy.
The facility failed to obtain consent for Risperdal for a resident and did not reinstate behavior tracking after a hospital visit. Another resident was not monitored for side effects after Risperdal was restarted, despite experiencing fatigue and decreased appetite. Staff interviews revealed a lack of clarity regarding responsibilities for consent and monitoring, and the facility's policies require medications to be prescribed for a diagnosed condition and monitored for efficacy and adverse consequences.
The facility failed to properly store and label medications in two medication carts. An LPN prepared medications for a resident without labeling the medication cups, and an inhaler was found without proper resident labeling or packaging. The DON confirmed that medications should be labeled with specific details, but deficiencies were observed.
The facility failed to implement its policy on food storage brought by visitors, leading to unsafe conditions in two residents' personal refrigerators. Observations showed expired and unlabeled food items, and incomplete temperature logs. Staff interviews revealed challenges in accessing residents' refrigerators due to their refusal, and no specific dietary aide was designated for checks.
A facility failed to ensure hospice notes were accessible and a comprehensive care plan was developed for a resident receiving hospice services. The resident's electronic medical record lacked up-to-date hospice notes, and staff were unclear about responsibilities for documentation. The facility had transitioned to an electronic system, but the process for receiving and uploading hospice notes was ineffective, leading to a gap in communication and documentation.
A facility failed to effectively track and monitor long-term antibiotic use for a resident, violating CDC guidelines and its own policies. The resident, with multiple health conditions, was on a long-term antibiotic without a stop date or documented justification from a urologist. Staff interviews revealed a lack of awareness and documentation regarding the resident's antibiotic regimen, leading to a deficiency in the facility's antibiotic stewardship program.
Inadequate Fall Prevention Measures Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of person-centered fall interventions for three residents, leading to multiple falls and significant injuries. Resident #89, with a history of falls and multiple fractures, was admitted with a care plan that did not accurately reflect her fall risk. Despite sustaining several falls, including those resulting in major injuries, the facility did not update her care plan with specific interventions tailored to her needs. The fall risk assessments were inaccurately documented, and the facility failed to conduct root cause analyses to determine the reasons for the falls. Resident #59, who also had a history of falls, experienced two falls during her stay, one of which resulted in a pelvic fracture. The facility did not add new interventions to her care plan following these incidents, and there was no root cause analysis conducted to identify the reasons for her falls. The existing care plan interventions were generic and not updated to address the specific circumstances of her falls. Resident #67, severely cognitively impaired, sustained a fall resulting in a wrist fracture. The facility's care plan for this resident included generalized fall interventions, but no new interventions were added after the fall. The facility's documentation did not accurately reflect the injuries sustained, and there was a lack of specific interventions to prevent further falls. The facility's failure to implement person-centered interventions and conduct thorough assessments contributed to the residents' falls and injuries.
Food Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in the main kitchen and nourishment rooms. Observations during a lunch meal service revealed that a cook, identified as CK #1, did not adhere to proper food handling protocols. CK #1 used a single glove for multiple tasks, including handling ready-to-eat foods, touching various surfaces, and using utensils, without changing gloves or washing hands in between tasks. This practice was contrary to the facility's Safe Food Handling policy and the Colorado Retail Food Establishment Regulations, which require the use of single-use gloves for only one task and mandate handwashing before handling food. Additionally, the facility failed to store food items correctly in the nourishment room refrigerators. Observations noted expired food items, including yogurt, milk, nutritional shakes, and rice pudding, in several hallway refrigerators. These items were not discarded despite the facility's policy requiring that food be stored, prepared, and served in accordance with professional standards for food service safety. The dietary manager and regional dietary consultant acknowledged that the nourishment refrigerators were checked twice daily, yet expired items were still found during the survey process. Interviews with the regional dietary consultant and dietary manager confirmed the deficiencies in food handling and storage practices. The regional dietary consultant noted issues with CK #1's food handling during the meal service and emphasized the importance of handwashing and using gloves for single tasks. Both the dietary manager and the regional dietary consultant admitted to finding and discarding expired items during the survey, indicating a lapse in the facility's adherence to its own policies and procedures for food safety.
Infection Control Deficiencies in Environmental Cleaning and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of proper disinfection of high-touch areas in residents' rooms. Observations revealed that a housekeeper did not disinfect door handles, call lights, television remotes, light switches, and bed control remotes in two separate rooms. Despite the facility's policy requiring daily disinfection of these areas, the housekeeper believed she had completed the task, indicating a gap in training or adherence to procedures. Interviews with the housekeeping supervisor and infection preventionist confirmed the importance of disinfecting high-touch areas to prevent infection spread, yet there was no documentation of audits or re-education efforts. Additionally, the facility did not ensure proper infection control practices during catheter care. A certified nurse aide (CNA) was observed performing Foley catheter care without changing gloves or performing hand hygiene after cleaning a dirtier area before moving to a cleaner area. This practice risks contaminating the sterile catheter system. The CNA admitted to being less familiar with male catheter care, and interviews with other staff highlighted inconsistencies in catheter care practices, with varying frequencies and methods reported. The director of nursing acknowledged the need for glove changes and hand hygiene during catheter care to prevent contamination. However, the observed practices did not align with the facility's policy, which emphasizes maintaining a closed drainage system and using aseptic techniques. These deficiencies in infection control practices, both in environmental cleaning and catheter care, indicate a failure to adhere to established protocols, potentially compromising resident safety.
Failure to Honor Resident's Therapy Preferences
Penalty
Summary
The facility failed to honor the preferences of a resident regarding the scheduling of rehabilitation therapy, which is a violation of resident rights. The resident, who was cognitively intact and required assistance with transfers and personal care, expressed a desire to know her therapy schedule to participate in other activities and manage her pain effectively. Despite her requests, the resident was not informed of her therapy schedule, leading to anxiety about missing sessions and difficulty in managing her pain. Observations and interviews revealed that the facility did not assess or document the resident's therapy preferences upon admission or during her stay. The resident's care plan and electronic medical records lacked any indication of her therapy preferences. The Director of Rehabilitation admitted to not documenting resident preferences and did not attend the resident's care conference, nor did any other therapist in her place. This lack of communication and documentation resulted in the resident not being able to plan her activities or manage her pain effectively. Interviews with staff, including the Director of Nursing and a physical therapist, indicated that while there were procedures in place to assess resident preferences, they were not followed in this case. The physical therapist mentioned that therapy schedules were sometimes adjusted based on resident needs, such as pain management, but this was not done for the resident in question. The failure to assess and document the resident's preferences led to a deficiency in honoring her right to self-determination and choice in her care.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into the care plan for a resident diagnosed with schizoaffective disorder, chronic kidney disease stage 3, and dementia with behavioral disturbance. The PASRR Level II evaluation recommended that the resident's medications and symptoms of psychosis be monitored by a psychiatric medication prescriber. However, the resident had not been seen by a psychiatric provider since January 2024, and there was no documentation in the resident's electronic medical record (EMR) to indicate why this follow-up had not occurred. Interviews with facility staff revealed a lack of awareness and implementation of the PASRR Level II recommendations. The social services director was unaware that the resident was to be followed by a psychiatrist for medication management, and the nursing home administrator stated that all PASRR Level II recommendations should be followed, noting that any refusal of psychiatric care by the resident should be documented. However, the resident's EMR did not contain any documentation of such a refusal. The director of nursing confirmed that PASRR Level II recommendations should be implemented timely and documented if refused by the resident.
Failure to Include Hand Brace in Restorative Program
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically regarding the use of a hand brace for a left hand contracture. The resident, who was cognitively intact and required substantial assistance with mobility, had a contracture in the left hand due to a stroke. The facility did not include the use of the resident's navy blue hand brace in the restorative program or comprehensive care plan, nor was there a physician's order for its use. Observations and interviews revealed that the resident wore the navy blue brace inconsistently, without a set schedule for donning and doffing. The resident reported wearing the brace for only a few hours a day and was unsure when it would be applied. Staff interviews confirmed the lack of a documented schedule or physician's order for the brace, and the restorative nurse aide and LPN overseeing the program were unaware of the specifics regarding the brace's use. The facility's oversight included a failure to incorporate the hand brace into the resident's care plan and restorative program, as well as a lack of communication and documentation regarding its use. The director of nursing acknowledged that the brace should have been included in the restorative program and care plan, with clear instructions on its application frequency and duration.
Failure to Obtain Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter, as per professional standards. The resident, who was admitted with a urinary catheter, did not have a physician's order for routine catheter care, maintenance, or monitoring. The baseline care plan did not document the presence of a urinary catheter, although the comprehensive care plan noted its necessity for healing surgical wounds. Despite this, there was no physician's order for flushing the catheter, which was performed by a nurse when the catheter was leaking. Interviews with staff revealed a lack of clarity and adherence to protocol regarding catheter care. A CNA stated that catheter care was provided every shift based on the electronic charting system, while an RN and LPNs acknowledged the need for physician's orders for catheter care and maintenance. The LPNs and the unit manager confirmed that flushing a catheter required a physician's order, which was absent in this case. The unit manager and the DON both emphasized the importance of having physician's orders to guide care and prevent infection. The DON admitted that it was the responsibility of the admitting nurse to ensure that physician's orders were obtained for catheter care upon admission. However, this was not done, leading to a lack of documented orders for the resident's catheter care. The oversight in obtaining these orders was not explained, and the facility recognized the need for a performance improvement plan to address the issue.
Failure to Administer and Label Tube Feeding Correctly
Penalty
Summary
The facility failed to ensure that a resident with a percutaneous endoscopic gastrostomy (PEG) tube received the prescribed treatment and services to prevent complications. Specifically, the facility did not administer the resident's tube feeding as ordered by the physician and failed to label the tube feeding containers with necessary information such as the resident's name, room number, date, start time, formula type, feeding rate, and nurse initials. These deficiencies were identified through observations, record reviews, and staff interviews. The resident in question, who is under 65 years old, was admitted with multiple diagnoses including dysphagia, protein-calorie malnutrition, and quadriplegia. The resident was alert but non-verbal and dependent on staff for all activities of daily living. Observations revealed that the resident's tube feeding was not administered according to the physician's order, as the feeding pump was found disconnected and off before the scheduled end time. Additionally, the tube feeding formula and water flush bags were unlabeled, and the water flush rate did not match the current physician's order. Interviews with a registered nurse (RN) confirmed that the tube feeding should have been administered per the physician's order and that labeling the feeding bags was crucial to prevent medication errors. The RN acknowledged the importance of adhering to the prescribed water flush rate, as it was the resident's only source of hydration due to their NPO status. The failure to provide the correct water flush rate could lead to dehydration or fluid overload, posing potential harm to the resident.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to use a person-centered approach in determining the use of a grab bar/bed rail for a resident, leading to a deficiency. The resident, who was over 65 years old and had diagnoses including dementia and a history of falling, was found to have a grab bar/bed rail attached to their bed without proper assessment for entrapment risks. The facility did not obtain informed consent from the resident or their representative, nor did they document any alternatives to the use of the grab bar/bed rail. Observations revealed a gap between the mattress and the grab bar/bed rail, indicating potential safety risks. Interviews with staff, including a CNA, LPN, and PT, highlighted a lack of documentation and communication regarding the installation and maintenance of the grab bar/bed rail. The PT mentioned that the therapy team should assess and approve such equipment, but there was no record of this process being followed for the resident. The facility's policy required assessments and informed consent before installing bed rails, but these procedures were not adhered to in this case. The NHA discovered that the resident's representative had installed the grab bar/bed rail, which was not documented in the resident's care plan. The DON emphasized the importance of evaluating residents for potential hazards associated with bed rails, but this was not done for the resident in question.
Failure to Obtain Consent and Monitor Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that two residents were as free from unnecessary medications as possible, specifically in the administration and monitoring of antipsychotic medications. For one resident, the facility did not obtain consent for the use of Risperdal until three months after the medication had been prescribed and administered. Additionally, behavior tracking for this resident was not reinstated after a hospital visit, despite the resident's history of verbal aggression and inappropriate behavior. Interviews with staff revealed a lack of clarity regarding responsibility for obtaining consent and ensuring behavior tracking was in place. Another resident was not monitored for side effects of Risperdal after the medication was restarted. The facility's records did not show any monitoring for side effects over several months, despite the resident experiencing fatigue and decreased appetite, which were noted in progress notes. Staff interviews indicated that side effect monitoring should have been documented in the medication administration record (MAR) each shift, but this was not done. The facility's policies and procedures require that psychotropic medications be prescribed for a diagnosed condition and not used for convenience. Medications should be monitored for efficacy and adverse consequences, and consent should be obtained prior to administration. The deficiencies identified in the report highlight failures in adhering to these policies, resulting in residents receiving medications without proper consent and monitoring.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored and labeled according to professional standards of practice in two of six medication carts. During an observation, an LPN was seen preparing medications for a resident without labeling the medication cups with the contents or the resident's name. The LPN dispensed torsemide and magnesium oxide into separate cups, but did not label them. The LPN also added senna to the cup containing the split magnesium tablet without labeling it. The medications were locked in the cart without proper identification, and the LPN planned to administer them later. Additionally, an inhaler was found in a medication cart without resident labeling information or packaging containing resident information. The inhaler was marked with a number in black marker, which the LPN claimed was for the resident in a specific room. However, the inhaler was not stored in its original packaging with the necessary resident and prescription information. The DON confirmed that all medications should be labeled with specific details, but the inhaler was found out of its packaging and stored next to an unopened inhaler box.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, resulting in unsafe and unsanitary conditions in the personal refrigerators of two residents. Specifically, the facility did not ensure the safe and appropriate storage of food items in the personal refrigerators of Resident #51 and Resident #42. Observations revealed expired and unlabeled food items in Resident #51's refrigerator, including yogurt containers with expiration dates ranging from August to November, an unlabeled and undated sandwich, an uncovered cup of orange juice, and a milk carton with an expired date. Additionally, the temperature logs for Resident #51's refrigerator were incomplete, with missing records for several days in October and November. The facility's policy required daily temperature monitoring and documentation, as well as checking individual food items for expiration dates and discarding outdated food promptly. However, the observations indicated that these procedures were not consistently followed. The temperature logs for Resident #51's refrigerator were not maintained as required, with gaps in the recorded temperatures. Similarly, Resident #42's refrigerator had only one temperature recorded for November, with missing entries for several days. Interviews with facility staff, including a dietary aide and the dietary manager, revealed challenges in implementing the policy. The dietary aide mentioned difficulties in checking the residents' refrigerators due to residents' refusal to allow access. The dietary manager acknowledged ongoing issues with dietary aides being unable to assess the refrigerators and stated that the facility had not designated a specific dietary aide to perform these checks. The regional dietary consultant also noted that residents preferred to manage their own refrigerators and resisted staff assistance, further complicating compliance with the facility's policy.
Deficiency in Hospice Care Documentation and Planning
Penalty
Summary
The facility failed to meet the requirements for the provision of hospice care for a resident, specifically by not ensuring that hospice notes were readily accessible and that a comprehensive care plan was developed with a clear delineation of care responsibilities between the facility and hospice. The facility's policy required that each resident's plan of care include the most recent hospice plan and a description of services provided by the long-term care facility. However, the comprehensive care plan for the resident did not include these necessary interventions and delineations. The resident, who was over 65 years old and diagnosed with myelodysplastic syndrome, type 2 diabetes, and chronic respiratory failure with hypoxia, was admitted to hospice care services earlier in the year. Despite this, the electronic medical record for the resident only contained hospice notes up to a certain date, and the hospice binder at the nurses' station was not updated with current information. Interviews with staff revealed a lack of clarity on who was responsible for ensuring hospice notes were accessible, with some staff unaware of the transition to a fully electronic medical record system. The nursing home administrator and other staff members, including the director of medical records and social services director, were interviewed and acknowledged issues with the process of receiving and uploading hospice notes. The facility had recently transitioned to an electronic system, and the hospice binder was no longer in use, leading to a gap in communication and documentation. The social services director was responsible for incorporating the hospice care plan into the resident's comprehensive care plan but was unsure of the specific requirements for hospice care planning.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, specifically in tracking and monitoring the use of long-term antibiotics for a resident. The Centers for Disease Control and Prevention (CDC) guidelines emphasize the importance of specifying the dose, duration, and indication for all antibiotic courses, which the facility did not adhere to. The facility's policy, revised in May 2024, outlines the need for appropriate antibiotic use and monitoring, but these protocols were not effectively followed for the resident in question. The resident, over 65 years old, was admitted with several medical conditions, including benign prostatic hyperplasia, hydronephrosis, tracheostomy status, and chronic obstructive pulmonary disease. The resident was on a long-term antibiotic, Macrobid, for urinary tract infection (UTI) prevention without a specified stop date. The care plan did not reflect frequent UTIs or the use of a prophylactic antibiotic. During a hospital admission, the resident's antibiotic was changed to Keflex due to concerns about long-term Macrobid use causing interstitial lung disease. However, there was no documentation from a urologist justifying the long-term use of antibiotics in the resident's medical record. Interviews with facility staff, including the infection preventionist (IP) and director of nursing (DON), revealed a lack of awareness and documentation regarding the resident's antibiotic regimen. The IP mentioned using McGeer's Criteria for antibiotic use and tracking antibiotic use on paper, but there was no evidence of a systematic approach to monitoring. The regional nurse consultant (RNC) also noted the resident's antibiotic use but could not provide documentation from a urologist to justify it. This lack of documentation and oversight led to the deficiency in the facility's antibiotic stewardship program.
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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 Littleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Wind Crest | 1.5 mi | ★★★★★ | 0 | 0 |
| Littleton Care And Rehabilitation Center | 2.8 mi | ★★★★★ | 1 | 0 |
| Vi At Highlands Ranch Skilled Nursing | 3.1 mi | ★★★★★ | 0 | 0 |
| Cherrelyn Healthcare Center | 3.1 mi | ★★★★★ | 1 | 0 |
| Suites At Someren Glen Care Center, The | 4.5 mi | ★★★★★ | 4 | 0 |
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