Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Wheatridge Care Center during CMS and state inspections, most recent first.
A resident with multiple sclerosis and a history of falls, who required total staff assistance for showers, was left unsupervised in the shower room. The CNA assisting the resident left to seek help without using the call light, and the resident fell, sustaining a right femur fracture that required surgery.
The facility did not have a designated or certified infection preventionist to oversee the infection prevention and control program, as required by policy. Instead, the role was temporarily filled by staff members who lacked the necessary infection control certification, potentially affecting all residents.
Three residents receiving psychotropic medications did not have individualized, person-centered non-pharmacological interventions or behavior monitoring documented in their care plans or physician orders. Instead, generic interventions and behaviors were used, and staff lacked awareness and training on resident-specific approaches, resulting in inadequate documentation and monitoring of behaviors related to medication use.
Nursing staff failed to follow professional standards by not observing residents as they took oral medications and by leaving medications at the bedside or in residents' possession. In several cases, residents were not monitored for safe ingestion, including one who experienced difficulty swallowing and required intervention after a family member alerted staff. These actions were inconsistent with facility policy and accepted nursing practice.
The facility did not have a designated RN serving as the full-time DON, as required. Instead, DON duties were shared among an LPN, an RN serving as the MDS coordinator, and a regional clinical resource, with each holding separate full-time responsibilities. The NHA confirmed the absence of a full-time RN in the DON role, and records did not identify anyone currently acting as DON.
Surveyors identified deficiencies in kitchen sanitation, food storage, and staff hygiene, including unclean kitchen areas, improperly labeled and stored food, dented cans in dry storage, and staff entering the kitchen without hairnets or proper hand hygiene. The dietary manager acknowledged lapses in cleaning oversight, food labeling, and staff compliance with hygiene protocols.
Two residents with mental health diagnoses did not receive appropriate treatment and services to support their mental and psychosocial well-being. One resident with a history of suicide attempts and ongoing depressive symptoms was not monitored for suicidal ideation, and staff were unaware of her mental health history. Another resident, traumatized by a fall in the shower, expressed fear of showering but did not receive follow-up assessment or interventions, and staff failed to communicate her concerns to management.
A nurse failed to observe multiple residents taking their prescribed oral medications, instead leaving medication cups with residents and exiting the room without confirming ingestion. This practice resulted in a medication error rate of 24%, significantly exceeding the acceptable threshold. The nurse also demonstrated uncertainty about handling medication refusals, contrary to facility policy requiring direct observation of medication administration.
Surveyors found that drugs and biologicals, including insulin and Ozempic pens, were not labeled with open dates in two medication carts, and inhalers were stored unsanitarily and unlabeled in a basket. The medication storage room was observed to be unsanitary, with trash, used gloves, and other debris present. Staff interviews revealed a lack of knowledge regarding proper medication labeling and storage requirements.
A housekeeper failed to follow proper cleaning and disinfection protocols, including not removing personal hygiene items before spraying disinfectant, missing high-touch surfaces, and not performing correct hand hygiene between glove changes. The staff member also donned gloves while hands were still wet with sanitizer and did not clean certain surfaces after contact with soiled gloves, contrary to facility policy and CDC guidelines.
Resident Left Unsupervised in Shower Resulting in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, a history of falls, and significant weakness was left unsupervised in the main shower room. The resident required total staff assistance for activities of daily living, including showers, and was identified as being at risk for falls. Despite these needs, the resident was left alone during a shower, which resulted in an unwitnessed fall and a fracture of the right femur. The incident took place when a certified nurse aide (CNA) assisting the resident became unable to understand the resident's needs, leading to the resident becoming upset and agitated. The CNA left the resident unattended in the shower room to seek help from another staff member, rather than using the call light and remaining with the resident. Upon returning, the CNA found the resident on the floor with the shower chair tipped over her. The resident sustained a right femur fracture, which required surgical intervention and hospitalization. Interviews with staff confirmed that the resident should not have been left unsupervised due to her dependence on staff for showers and transfers. The facility's fall management policy required that interventions be implemented based on assessed needs and communicated to direct care staff. Documentation and staff statements indicated that the resident's care plan called for maximum assistance and supervision during bathing activities, but these measures were not followed at the time of the incident.
Failure to Employ 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 facility policy. The policy specified that the infection preventionist is responsible for coordinating, implementing, and updating the infection prevention and control program (IPCP), as well as providing education and training on evidence-based practices. The policy also required the IP to be employed onsite and at least part-time. However, during the survey, it was found that the facility did not have a designated person in charge of the IPCP, and the role was being temporarily filled by the regional clinical resource (RCR) and the minimum data set coordinator (MDSC), neither of whom had the required infection control certification. Interviews with the MDSC, NHA, and RCR confirmed that there was no designated or certified infection preventionist overseeing the IPCP at the time of the survey. The MDSC stated she did not oversee the IPCP and did not have the required certification, while the RCR, who was temporarily filling in, also lacked the necessary certification. The NHA acknowledged that the facility did not have a designated person in charge of the IPCP, and the RCR was only filling in until the position could be filled. This failure had the potential to affect all residents residing in the facility at the time of the survey.
Failure to Individualize Psychotropic Medication Management and Behavior Interventions
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and were receiving the least restrictive approach for their needs. Specifically, the facility did not provide resident-specific, non-pharmacological care approaches in the behavior care plans for residents who were prescribed psychotropic medications. For example, one resident with diagnoses including bipolar disorder, anxiety, depression, PTSD, and vascular dementia had care plans and physician orders that lacked individualized non-pharmacological interventions and did not include all relevant target behaviors such as physical and verbal aggression or delusions. Additionally, there was no documentation of behavior monitoring for antipsychotic medication use, and medication administration records showed no documentation of behaviors over several months. Another resident with bipolar disorder and dementia was prescribed antipsychotic and mood stabilizer medications, but the care plan did not identify medication-specific target behaviors or person-centered interventions for the mood stabilizer. Physician orders for behavior monitoring failed to include all relevant behaviors such as mania, racing thoughts, and psychosis, despite progress notes indicating the presence of these symptoms. There was also a lack of documentation showing that non-pharmacological interventions were attempted for these behaviors, and staff interviews revealed a lack of awareness and training regarding individualized interventions and behavior documentation. A third resident with schizophrenia and anxiety had care plans and physician orders that listed generic behaviors and interventions, which were not specific to the resident's actual behaviors such as paranoia, removing clothing, and inappropriate use of hand sanitizer. Documentation in the medical record indicated ongoing behavioral issues and medication adjustments, but the care plans and orders did not reflect these changes or provide individualized interventions. Staff interviews further revealed that CNAs and nurses were not familiar with resident-specific behaviors or interventions and relied on generic templates, with limited access to care plans and no formal training on documentation expectations.
Failure to Observe and Monitor Medication Administration
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of practice regarding medication administration for four residents. Specifically, nursing staff did not remain with residents to observe them swallowing their oral medications and, in several cases, left medications at the bedside or in the resident's possession without confirming ingestion. Facility policy and professional guidelines require that staff observe residents taking medications and do not leave medications unattended with residents. For one resident with peripheral vascular disease and malnutrition, a registered nurse handed the resident a cup containing metoprolol and Lyrica, then left the room before confirming the medications were taken. Another resident, admitted for low sodium and post-hip surgery pain, was given Tylenol and sodium chloride tablets; the nurse left the room without ensuring the medications were swallowed. This resident subsequently experienced difficulty swallowing, with water spilling from her mouth and a family member alerting staff to the situation. The nurse only returned after being notified of the issue. A third resident with rheumatoid arthritis was given Tylenol tablets while in bed at a 30-degree angle and eating lunch; the nurse did not reposition the resident upright or observe medication ingestion. For a fourth resident with a cognitive communication deficit, the nurse left a cup of liquid protein solution at the bedside after the resident initially refused it. Staff interviews confirmed that the nurse did not consistently observe residents taking medications and sometimes left medications in the room, contrary to facility policy and professional standards.
Failure to Designate Full-Time RN as Director of Nursing
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was designated as the full-time director of nursing (DON), as required. Record review showed that the facility's DON job description outlined essential administrative and supervisory functions, but the staff list provided did not identify anyone currently serving as the acting DON. The nursing home administrator (NHA) confirmed that there was no designated RN acting as the full-time DON at the time of the survey. Interviews with staff revealed that DON responsibilities were being shared among an LPN, the minimum data coordinator (MDSC), and a regional clinical resource (RCR). The LPN stated she was sharing DON duties with the MDSC and RCR, and the NHA confirmed that the facility had been without a full-time RN in the DON role for over a month. The MDSC, who is an RN, was also responsible for restorative therapy and MDS duties, and the RCR was not present in the building daily. Each of these roles was described as a full-time position, indicating that the DON responsibilities were not being fulfilled by a single, full-time RN as required.
Deficiencies in Kitchen Sanitation, Food Storage, and Staff Hygiene
Penalty
Summary
The facility failed to maintain food service operations in accordance with professional standards, resulting in multiple deficiencies related to kitchen cleanliness, food storage, and staff hygiene. Observations revealed that the kitchen and dish room were not kept clean and sanitary, with food debris found under preparation tables, shelves, and equipment, as well as buildup and grime on handwashing sinks and refrigerator handles. The floor had cracked and missing tiles, cove base was peeling or missing, and trash cans in the food preparation area were uncovered and often full. Equipment such as the large mixer and meat slicer were left uncovered when not in use, and the dish room had debris along the baseboards and under the dishwashing machine. The dietary manager acknowledged that cleaning schedules were not consistently checked and that maintenance issues had not been reported. Food storage practices were also deficient. In the walk-in refrigerator and freezer, several food items, including tinfoil-wrapped sandwiches and containers of dressing or sauce, were not labeled or dated. Some food items were stored directly on the floor, contrary to policy and regulations. In the dry storage area, dented cans of sauerkraut were found, which the dietary manager stated should have been returned to the supplier. The dietary manager confirmed that food should be labeled, dated, and stored off the floor, and was unaware of the presence of the dented cans. Additionally, staff failed to adhere to hygiene protocols by not wearing hairnets when entering the kitchen. On multiple occasions, a registered nurse and another unidentified staff member entered the kitchen without hairnets, with one staff member also failing to wash hands before handling items. The dietary manager confirmed that all employees entering the kitchen should wear hairnets, as required by professional standards.
Failure to Address Mental Health and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with mental disorders or psychosocial adjustment difficulties. For one resident with bipolar disorder, Parkinson's disease, and dementia, the care plan did not identify a history of suicide attempts or suicidal ideation, despite psychotherapy notes documenting such history and ongoing depressive symptoms. The resident expressed feelings of depression, loneliness, and discouragement, and made statements indicating possible suicidal ideation, but there was no evidence in the medical record that the facility was monitoring for signs and symptoms of depression or suicidal ideation. Staff interviews revealed a lack of awareness among CNAs, LPNs, and the social services director regarding the resident's mental health history and current symptoms, and the behavioral health notes were not regularly reviewed by the social services director. Another resident, with multiple sclerosis, bipolar disorder, and a recent major injury from a fall in the shower, expressed ongoing fear of taking showers after the incident. The resident reported this fear to several staff members and had not received a shower since the fall, instead receiving bed baths. Although the psychiatric evaluation noted the resident's fear, there was no follow-up assessment, evaluation, or referral to behavioral health services documented in the medical record. The care plan did not include interventions to address the resident's fear of showers, and staff who were aware of the concern did not report it to management or document it in the progress notes. Interviews with staff confirmed that the resident's fear was known to CNAs and LPNs, but this information was not communicated to the social services director or management. The social services director and primary care physician were unaware of the resident's expressed fear, and the regional clinical resource acknowledged a breakdown in communication and documentation. The lack of follow-up and failure to address the residents' mental health needs resulted in the facility not ensuring the highest practicable mental and psychosocial well-being for these residents.
Failure to Ensure Safe Medication Administration and Observation
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as required by policy, resulting in a medication error rate of 24% (six errors out of 25 opportunities). Observations revealed that a registered nurse (RN) repeatedly did not observe residents swallowing their oral medications. In several instances, the RN dispensed medications into cups, handed them to residents, and left the room without confirming ingestion. For example, one resident was given metoprolol and Lyrica, another was given Tylenol and sodium chloride, and a third was given Tylenol while eating lunch and not properly positioned. In each case, the RN did not remain to ensure the medications were taken as prescribed. Additionally, the RN left a cup of liquid protein supplement with a resident who refused it, instructing the resident to drink it but leaving the room without confirming compliance. Interviews with the RN revealed a lack of understanding regarding the need to observe residents taking medications and uncertainty about how to handle medication refusals. The facility's policy clearly states that staff must observe residents swallowing oral drugs and not leave medications with them, but these procedures were not followed during the observed medication passes.
Improper Storage and Labeling of Medications and Unsanitary Medication Room Conditions
Penalty
Summary
Surveyors identified that the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of three medication carts and one of two medication storage rooms. Specifically, insulin pens (Humalog, Lantus, and Semgee) and an Ozempic pen were found in medication carts without open dates, contrary to manufacturer instructions and facility policy, which require labeling with the date opened to ensure medications are not used past their safe period. Additionally, the vaccine storage refrigerator contained both vaccines and insulin, which is not in accordance with proper storage practices. Further observations in the medication storage room revealed unsanitary conditions, including a large trash bin filled with trash, a basket with used gloves and food wraps, a non-working bidet filled with plastic and paper scraps, and a box with filled sharps containers. The room also contained a deflated air mattress in a dusty sink, an empty bucket, a brush, and a broken walker. The countertop was stained and dusty, and the controlled emergency medication box was stored on top. These conditions do not meet standards for sanitary storage of medications and supplies. In one medication cart, a basket was found containing seven inhalers, some missing mouthpiece covers and two without resident names, which is not compliant with labeling and sanitary storage requirements. Interviews with nursing staff revealed a lack of knowledge regarding the importance of labeling insulin pens and proper storage of inhalers. Staff were also unaware of the specific timeframes for safe use of medications after opening, and could not locate the binder with medication expiration dates.
Failure to Maintain Infection Control Due to Improper Cleaning and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of its units, as evidenced by improper cleaning techniques and inadequate hand hygiene practices by housekeeping staff. During a continuous observation, a housekeeper was seen cleaning resident rooms and bathrooms without following established protocols. Specifically, the housekeeper did not remove residents' personal hygiene items from the bathroom counter before spraying disinfectant, failed to disinfect high-touch areas such as door knobs, bed remotes, call lights, light switches, over-bed tables, and night stands, and did not clean the bathroom door knob after touching it with soiled gloves. The housekeeper also used a wet rag from a bucket containing sanitizing solution to wipe down surfaces and handled cleaning equipment and room surfaces with the same gloves, increasing the risk of cross-contamination. Hand hygiene practices were not properly followed, as the housekeeper applied alcohol-based hand sanitizer and immediately donned gloves while her hands were still visibly wet, rather than allowing the sanitizer to dry as required. On several occasions, the housekeeper changed gloves without performing hand hygiene in between, and did not rub her hands with sanitizer until dry before putting on new gloves. These actions were inconsistent with both facility policy and CDC guidelines, which emphasize the importance of proper hand hygiene and thorough cleaning of high-touch surfaces to prevent the transmission of healthcare-associated infections. Interviews with the housekeeper revealed that she was primarily a laundry attendant and only occasionally worked as a housekeeper. She acknowledged receiving training on housekeeping and hand hygiene but admitted to forgetting to clean high-touch areas and not allowing her hands to dry after using hand sanitizer. The maintenance director was unaware of his responsibility for housekeeping oversight, and the regional clinical resource confirmed that staff were trained at hire and annually, reiterating the importance of proper cleaning and hand hygiene practices.
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Illustrative
What surveyors actually found near you
We read the 526 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Rehabilitation Center At Sandalwood, The | 0.8 mi | ★★★★★ | 7 | 0 |
| Lakeside Post Acute | 0.9 mi | ★★★★★ | 2 | 0 |
| Cambridge Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Edgewater Health And Rehabilitation | 1.1 mi | ★★★★★ | 14 | 0 |
| Cedars Healthcare Center | 1.2 mi | ★★★★★ | 0 | 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.