Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Rehabilitation Center At Sandalwood, The during CMS and state inspections, most recent first.
A housekeeper was observed cleaning two resident rooms without following the facility’s infection control procedures or the disinfectant’s dwell time requirements. She used the same gloves and cleaning materials across the bathroom, sink, and bedside areas, did not consistently clean from cleanest to dirtiest, failed to keep some surfaces wet for the required contact time, and did not clean identified high-touch items such as call buttons, light switches, door handles, and TV remotes. Interviews confirmed the EVS director expected daily cleaning of high-touch surfaces and separate cleaning practices for bathroom and room areas, while the housekeeper reported she had not been trained in her native language.
A resident with intact cognition and multiple chronic conditions was not given a true choice about where to keep personal funds. Staff contacted the POA about cash kept in the resident’s room, encouraged use of the resident fund account because of concerns about misplaced money, and the resident later stated he wanted to keep his money in his room but was told to bring it to the front desk for deposit.
A resident with dementia, epilepsy, heart failure, and a history of falls was identified as a high fall risk and dependent on staff for all ADLs. After a fall, an LPN documented that the resident was found sitting in a chair and denied pain, but there was no documentation that an RN completed or was consulted for the assessment. Staff interviews confirmed that RN assessment was expected after a fall, yet the event note did not show it occurred.
The facility failed to provide needed ADL assistance for two residents. One resident with COPD, CKD, Alzheimer’s disease, and muscle weakness had repeated observations of a dirty top denture, while records showed oral care was not consistently provided as documented. Another resident with hemiplegia, dysphagia, and weakness was observed trying to eat without the one-to-one meal assistance documented in the care plan, despite staff and family reports that meal support was needed.
The facility failed to ensure timely review and response to drug regimen recommendations identified by the consulting pharmacist, affecting four residents. The CP reported not receiving responses to her recommendations for four months, despite notifying the medical director, DON, and NHA. Numerous MRR recommendations from January to April 2024 were not reviewed by the medical provider until the survey. The deficiency created a situation of immediate jeopardy for serious resident harm due to the lack of timely oversight of medication therapies.
A resident with multiple food allergies and medical conditions experienced a severe weight loss of 27.7% over six months due to the facility's failure to provide timely and effective interventions. Despite requests for reweighs and physician orders for weekly weight monitoring, the facility did not consistently weigh the resident or implement timely nutritional interventions. The resident's care plan lacked specific weighing frequency, and there was inadequate documentation of nutritional supplement consumption. Staff interviews revealed communication and follow-up issues regarding the resident's weight monitoring and nutritional needs.
The facility's QAPI program failed to address issues in the medication regimen review (MRR) process, leading to a lack of timely communication of pharmacist recommendations to physicians. This oversight created a situation of immediate jeopardy, as the consultant pharmacist had not received responses from providers since January 2024, compromising resident safety and medication management.
A resident with a cognitive communication deficit was not provided with appropriate communication tools or a person-centered care plan to address his needs. Despite being cognitively intact, the resident struggled to communicate effectively, and the facility failed to incorporate recommendations from speech-language pathology services into his care plan. Staff interviews revealed a lack of communication and follow-up, resulting in inconsistent care for the resident.
A resident with obstructive sleep apnea experienced skin irritation due to an ill-fitting CPAP mask. Despite complaints and visible redness, the facility delayed ordering a new mask and failed to document wound care orders. Staff interviews revealed awareness of the issue but a lack of documentation and timely action, resulting in ongoing skin irritation.
The facility failed to provide appropriate care for two residents with limited ROM. One resident was not consistently monitored for splint use, with no documentation indicating compliance with OT recommendations. Another resident was improperly positioned in her wheelchair, causing discomfort, and lacked a proper care plan for positioning. Staff interviews revealed a lack of awareness and documentation regarding these issues.
The facility failed to ensure a safe environment by not completing neurological checks after unwitnessed falls for a resident and not properly training staff for slide board transfers, leading to falls for two residents. The DON acknowledged the oversight in neurological checks, and the NHA confirmed that involved CNAs had not received necessary training.
A facility failed to ensure consistent communication and documentation with a dialysis center for a resident requiring dialysis services. The facility's policy required coordination of care, including communication about vital signs and medications, to be sent with the resident to dialysis appointments. However, missing hemodialysis communication forms on several dates indicated a lack of documentation and communication. Staff interviews confirmed the inconsistency, and despite efforts, the missing forms were not located by the end of the survey.
A resident with a broken tooth did not receive timely dental care due to a lack of communication and coordination between the facility and the mobile dental team. Despite reporting the issue in March, the resident was not seen by a dentist until late April, as the dental team was not informed of the emergency need and left the facility during a state survey.
Infection Control Deficiencies in Room Cleaning and Disinfection
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment on two of three units. During observations, a housekeeper was seen cleaning two double-occupancy resident rooms in a manner that did not follow the facility’s own room disinfection procedures or the manufacturer’s dwell-time instructions for the hydrogen peroxide disinfectant. The housekeeper used the same gloves and cleaning materials across multiple surfaces and areas, did not consistently clean from cleanest to dirtiest, and did not complete hand hygiene between tasks as described in the report. In the first room, the housekeeper entered the bathroom first, sprayed the toilet and other bathroom surfaces with hydrogen peroxide, and timed the one-minute dwell time on her phone. While waiting, she sprayed a dry rag and wiped the grab bars, but the grab bars did not remain wet for the required dwell time. She then cleaned the toilet using the same rag, failed to clean the toilet handles, and did not follow a clean-to-dirty sequence. After removing her gloves and washing her hands, she returned to the room, placed clean rags on a chair, and cleaned the sink area without waiting for the disinfectant dwell time before turning on the water or scrubbing. She then moved to the bedside table on one side of the room without changing gloves or performing hand hygiene after cleaning the sink, and later swept and mopped across the bathroom and both sides of the room using the same mop pad and contaminated mop bucket solution. In the second room, the housekeeper again began in the bathroom and cleaned the toilet riser and toilet in a sequence that did not follow cleanest-to-dirtiest order. She failed to keep the grab bars and shelf wet for the required one-minute dwell time, then cleaned the sink area and bedside table while using the same gloves and materials across tasks. She also failed to change gloves after cleaning the sink before moving to the other side of the room, failed to use separate mop pads for the different areas of the room and bathroom, and contaminated the mop water by reaching into it with soiled gloves. The observations also showed that high-touch surfaces such as call buttons, light switches, door handles, and television remotes were not cleaned in the rooms. Interviews confirmed that the environmental services director identified these items as high-touch surfaces and stated they should be cleaned daily, while the housekeeper stated she had not been trained in her native language and was unsure what high-touch surfaces were.
Resident Choice for Personal Funds Not Honored
Penalty
Summary
The facility failed to provide a resident choices regarding the storage of personal funds for one resident. The resident was cognitively intact with a BIMS score of 15 out of 15 and had diagnoses including cancer, type 2 diabetes, heart failure, and chronic kidney disease. Record review showed the business office manager contacted the resident’s POA about money the resident was keeping in his room and suggested depositing it into the resident fund management system. Shortly afterward, the resident’s money was deposited into the account, and the account later showed a balance of $210.00. During interview, the resident stated he wanted to keep his money in his room and said the facility had previously allowed him to keep about $200.00 to $300.00 in a locked drawer with a key. He reported that after using the locked drawer for about a day, a staff member told him he had to bring the cash to the front desk, and he was upset because he preferred having cash available in his room. Staff interviews confirmed that residents could keep money in their rooms, but the BOM and receptionist described staff concerns about residents misplacing cash and said the resident was encouraged to place his money in an account before it was deposited.
RN Assessment Not Completed After Resident Fall
Penalty
Summary
The facility failed to ensure that services provided in accordance with the resident's plan of care were delivered by a qualified person when Resident #80 was not assessed by an RN after a fall. The resident was greater than 65 years old, admitted with diagnoses including cerebral atherosclerosis, epilepsy, dementia, heart failure, and a history of falling. The MDS showed short-term and long-term memory problems, severe impairment in daily decision making, and dependence on staff for all ADLs. Her fall care plan identified her as at risk for falling due to confusion, deconditioning, incontinence, poor communication and comprehension, lack of awareness of safety needs, restlessness, and agitation. The fall risk assessment documented the resident as a high fall risk, and a nursing progress note written by an LPN stated that the resident fell while the LPN was on break. The note documented that the resident was found sitting in a chair, denied pain, and was able to move all extremities, but it did not document that an RN completed an assessment or was consulted regarding the fall. During interviews, the LPN said an RN should be called to assess a resident before moving them after a fall, and a CNA said she would call for the nurse and stay with the resident when a fall occurred. The DON and regional clinical resource stated the RN assessment was not part of their plan of correction.
Failure to Provide ADL Assistance for Oral Care and Meals
Penalty
Summary
The facility failed to provide assistance with activities of daily living for two residents, including denture care for one resident and meal assistance for another resident. The report states that the facility’s ADL policy required residents’ abilities in ADLs to be maintained unless deterioration was unavoidable, and that residents unable to perform ADLs were to receive necessary services to maintain good nutrition, grooming, and oral hygiene. For the resident who needed oral care, the record showed diagnoses including COPD, CKD, Alzheimer’s disease, and muscle weakness, with mild cognitive impairment and a need for setup or clean-up assistance with oral hygiene. Surveyors observed the resident’s top denture on multiple occasions with whitish-yellow or yellow film caked on the palate side and along the tooth and gum sides. The resident said she cleaned her dentures herself, but a family member stated the resident needed help cleaning the top denture and that the denture often did not seem clean. A CNA later brushed the denture, after which it was pink and free of the coating. The care plan documented partial assistance with personal hygiene and oral care, but point-of-care charting showed oral hygiene was documented only once daily on several days, and one entry documented the resident completed oral hygiene independently despite the MDS indicating she needed setup or cleanup assistance. For the resident who needed meal assistance, the record showed diagnoses including hemiplegia/hemiparesis following cerebral infarction, dysphagia, and muscle weakness. The MDS documented dependence for multiple ADLs and substantial/maximal assistance with eating. The resident’s representative said staff would place the meal tray and leave, and that it took a long time for staff to return. During a continuous observation, the resident was seen attempting to feed herself while no staff provided one-to-one meal assistance; later, staff entered briefly, asked if anything was needed, and left without providing meal assistance. The care plan and nutrition plan documented substantial assistance and one-to-one meal assistance, and the dietitian recommended one-to-one assistance with meals. However, staff interviews showed conflicting information about whether the resident needed one-to-one assistance, set-up only, or supervision, and the resident was observed without the meal assistance documented in the care plan during the survey observation.
Failure to Review and Act on Drug Regimen Recommendations
Penalty
Summary
The facility failed to implement policies and procedures to ensure that potential irregularities identified by the consulting pharmacist (CP) in monthly drug regimen reviews (MRRs) were timely reviewed and acted upon by the medical provider, medical director, and the director of nursing (DON). This deficiency affected four residents whose records were reviewed. The CP reported that she had not received any response to her MRR recommendations for four months, starting in January 2024, despite notifying the medical director, DON, and nursing home administrator (NHA) about the lack of response. A review of an executive summary report by the pharmaceutical company revealed that numerous MRR recommendations from January to April 2024 had not been returned to the CP to show they had been reviewed and responded to by the medical provider. During the survey, it was found that MRRs for the affected residents were not reviewed and signed by the medical provider until the survey was conducted. The MRRs included recommendations for addressing medications with anticoagulation properties, antipsychotic medications without appropriate indications, and antidepressants, among others. Interviews with the CP and review of the facility's policy and procedures indicated that the facility's leadership was aware of the problem with MRR reviews and responses. The CP had informed the medical director, another physician, the DON, and the NHA about the issue, but no corrective actions were taken until the survey revealed the deficiency. The facility's failure to ensure timely review and response to MRR recommendations created a situation of immediate jeopardy for serious resident harm due to the lack of timely oversight of the residents' medication therapies.
Removal Plan
- MRRs for Residents #51, #15, #60, and #64 were reviewed and given to residents' providers for review and follow up on recommendation. Based on physician review, appropriate changes were made to residents' medication regimens as needed.
- Family and physician notification for Resident #51, #15, #60 and #64 was completed.
- Education completed with DON and assistant director of nursing (ADON) regarding follow up with MRRs.
- DON/designee began reviewing MRRs with resident's provider to assure recommendations were reviewed by the provider. This included all residents with recommendations. All recommendations will be reviewed and completed by residents' providers.
- The DON/designee will begin reporting to the NHA and vice president (VP) of Clinical Services to ensure monthly MRR follow up has been completed. Review tool to be completed to document completing of review.
- The pharmacy consultant will email monthly reports to the attending physician, the Medical Director, DON, NHA, VP of Clinical Services, and Director of Operations for review and follow up. In addition, hard copies will be provided to providers during regular visits to the community.
- Facility pharmacy consultant will complete an Interim Medication Regimen Review (IMRR) on all new residents admitted to the facility twice per week to ensure new admissions are reviewed that would discharge from the facility prior to when monthly MRRs are completed.
- MRRs will be reviewed monthly by DON/designee to ensure recommendations have been reviewed/completed by the provider. Findings will be reported to the QAPI (quality assurance performance improvement) meeting held monthly for further review and recommendation.
Failure to Prevent Severe Weight Loss in Resident
Penalty
Summary
The facility failed to provide timely and effective interventions to prevent significant weight loss for a resident with multiple food allergies and medical conditions, including hyper-[NAME] syndrome, anemia, and dementia. The resident experienced a severe weight loss of 27.7% over six months, from 139 lbs to 100.5 lbs. Despite the registered dietitian's (RD) requests for reweighs and the physician's orders for weekly weight monitoring, the facility did not consistently weigh the resident or implement timely nutritional interventions. The facility's inaction included failing to obtain reweighs promptly when requested by the RD, delaying the implementation of nutritional interventions, and not following physician orders for weekly weight monitoring. The resident's care plan did not specify the frequency of weighing, and the facility did not document how much of the nutritional supplements the resident consumed. Additionally, the facility did not hold interdisciplinary team meetings to address the resident's weight loss, and the resident did not receive adequate assistance and supervision during meals. Interviews with staff revealed a lack of communication and follow-up regarding the resident's weight monitoring and nutritional needs. The RD was aware of the resident's continued weight loss but did not ensure the resident was weighed weekly. The facility's failure to monitor the resident's weight closely and implement timely nutritional interventions resulted in the resident's severe weight loss over six months.
Failure in Medication Regimen Review Process
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to address compliance concerns, specifically related to the medication regimen review (MRR) process. The QAPI committee did not identify and address issues with the timely communication of pharmacist recommendations to physicians, which is crucial for ensuring appropriate medication management for residents. This oversight led to a situation where serious adverse outcomes were likely, rising to the level of immediate jeopardy. Interviews and record reviews revealed that the facility's process for handling MRR forms was inadequate. The forms, containing pharmacist recommendations, were placed in a box at the nurses' station for providers to review. However, there was no effective system to ensure that these recommendations were communicated to physicians in a timely manner. As a result, the consultant pharmacist had not received responses from providers since January 2024, indicating a significant lapse in the medication management process. The nursing home administrator (NHA) confirmed that the QAPI committee met monthly and included required members, but it had not identified concerns from the MRR. The committee was focused on other issues such as falls, weight loss, and pressure ulcers, but failed to address the critical issue of medication management. This lack of attention to the MRR process contributed to the facility's failure to ensure resident safety and appropriate medication use.
Failure to Address Communication Needs of a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the abilities of a resident with a cognitive communication deficit. The resident, who was 90 years old and had diagnoses including heart disease, depression, dysphagia, and cognitive communication deficit, was observed to have difficulty communicating his needs effectively. Despite being cognitively intact with a BIMS score of 14 out of 15, the resident required substantial assistance with daily activities and used a tube feeding for eating. The facility did not provide a communication tool or create a person-centered care plan addressing the resident's communication deficits. Observations and interviews revealed that the resident was unable to respond to simple questions and there were no communication aids or instructions in his room. The comprehensive care plan lacked interventions related to the resident's communication needs, and there was no evidence of continuity of care following the discharge from speech-language pathology (SLP) services. The SLP evaluation had identified a need for moderate cueing and assistance, but these recommendations were not incorporated into the resident's care plan. Interviews with staff, including the Director of Rehabilitation and the Director of Nursing, indicated a lack of communication and follow-up regarding the resident's care plan. The Director of Rehabilitation acknowledged that therapy staff did not update care plans and suggested the use of signage or a communication board. The Director of Nursing admitted that a communication care plan was necessary for new or agency staff to understand how to interact with the resident. Despite some caregivers having effective communication techniques, these were not documented in the care plan, leading to inconsistent care for the resident.
Failure to Timely Address CPAP Mask Fit Leads to Resident Skin Irritation
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with obstructive sleep apnea, chronic respiratory failure, and dependence on supplemental oxygen. The resident, who was cognitively intact, experienced skin irritation due to an ill-fitting CPAP mask. Despite the resident's complaints and visible redness on the bridge of his nose, the facility did not take timely action to address the issue. The resident's care plan, which included checking the CPAP mask for correct fit and replacing it if necessary, was not followed. A skin tear was identified on the resident's nose, and it was reported to the medical provider. However, there were no wound care orders or monitoring documented in the resident's medical records. The facility delayed ordering a new CPAP mask, and the resident continued to experience skin irritation. Interviews with staff revealed that the assistant director of nursing was aware of the issue but did not document conversations or track the redness on the resident's nose. The licensed practical nurse confirmed the absence of a physician's order for wound care or monitoring. The facility's inaction and lack of documentation contributed to the ongoing skin irritation experienced by the resident.
Deficiencies in ROM Care and Wheelchair Positioning
Penalty
Summary
The facility failed to provide appropriate care for two residents with limited range of motion (ROM), leading to deficiencies in their treatment and services. Resident #15, a 75-year-old with hemiplegia and contractures following a stroke, was not consistently monitored for the use of her prescribed splints. Observations revealed that the resident was not wearing her splints during a two-hour period, and there was no documentation in the medical records to indicate that the splints were applied as recommended by occupational therapy. Interviews with staff indicated a lack of awareness and documentation regarding the resident's splint use, and the comprehensive care plan did not include a focus on the use of splints for contractures. Resident #10, a 70-year-old with multiple diagnoses including hemiplegia and cervicalgia, was not properly positioned in her wheelchair, causing discomfort and pain. Observations showed the resident's head was consistently tilted in an uncomfortable position, and interviews revealed that the resident had requested a new head brace, which had not been provided. The comprehensive care plan did not include instructions on how to properly position the resident in her wheelchair, and staff interviews indicated a lack of clear guidance on positioning. The deficiencies in care for both residents were due to inadequate monitoring, documentation, and communication among staff regarding the residents' specific needs for splint use and wheelchair positioning. The lack of proper documentation and care planning contributed to the failure to maintain or improve the residents' range of motion and comfort, as required by their care plans and medical needs.
Deficiencies in Fall Management and Staff Training
Penalty
Summary
The facility failed to provide an environment free from accident hazards and risks for three residents. Resident #60 experienced multiple unwitnessed falls, and the facility did not complete the required neurological checks following these incidents. Despite the facility's policy mandating neurological evaluations for unwitnessed falls, there was no documentation to confirm that these checks were performed after falls on 12/23/23, 2/5/24, and 3/23/24. The Director of Nursing acknowledged the oversight and the importance of these checks in identifying potential neurological issues. Additionally, the facility did not ensure that staff were properly trained to assist with slide board transfers, leading to falls for Resident #52 and Resident #43. Resident #52, who had paraplegia and other health conditions, fell during a slide board transfer due to the lack of training for CNA #2, who was involved in the incident. Similarly, Resident #43, who had moderate cognitive impairment and muscle weakness, fell during a transfer because CNA #3 had not attended the necessary training sessions. Interviews with the Nursing Home Administrator confirmed that both CNAs involved in the incidents with Residents #52 and #43 had not received the required training on slide board transfers. The lack of immediate training for these CNAs after the falls further contributed to the deficiency in ensuring safe transfer practices for residents at risk of falls.
Deficiency in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure consistent communication and documentation with the dialysis center for a resident requiring dialysis services. The facility's policy required coordination of dialysis care, including communication about vital signs, medications, and other care concerns, to be sent with the resident to their dialysis appointments. However, a review of the resident's records revealed missing hemodialysis communication forms on several dates, indicating a lack of documentation and communication between the facility and the dialysis center. Interviews with facility staff, including LPNs, the dialysis registered nurse, and the director of nursing, confirmed that the communication forms were not consistently completed or returned from the dialysis center. The director of nursing acknowledged the missing forms and stated that the facility should have contacted the dialysis center to obtain the necessary documentation. Despite efforts to locate the missing forms, they were not provided by the end of the survey, highlighting a deficiency in maintaining proper communication and documentation for the resident's dialysis care.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to provide timely dental care to a resident who sustained a broken tooth. The resident, who was under 65 years old and cognitively intact, reported the issue to multiple staff members in March 2024, expressing that the broken tooth was painful and affected her ability to chew. Despite being on a rotating schedule with a mobile dental team for routine visits, the resident's need for emergency dental care was not addressed promptly. The facility's ancillary care plan indicated that staff were responsible for scheduling necessary appointments, but there was no documentation that the resident was scheduled for emergency dental services in March. The social services coordinator (SSC) was first informed of the resident's dental issue on March 17, 2024, but it was not until April 23, 2024, that the resident was scheduled to see a dentist. However, the dental team did not see the resident on that day because she was not on the list, and the team reportedly left the facility due to an ongoing state survey. The vice president of operations for the dental team confirmed that they were not notified of the resident's need for emergency services in March and that the facility had asked the dental team to leave during the survey. This lack of communication and coordination resulted in the resident not receiving the necessary dental care in a timely manner.
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Illustrative
What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wheat Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Post Acute | 0.5 mi | ★★★★★ | 2 | 0 |
| Wheatridge Care Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Cambridge Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Edgewater Health And Rehabilitation | 1.9 mi | ★★★★★ | 14 | 0 |
| Cedars Healthcare Center | 1.9 mi | ★★★★★ | 0 | 0 |
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