VILLAGE CARE AND REHABILITATION CENTER, THE

WESTMINSTER, CO · 60 beds · Non profit - Church related

33 Trust Score
Grade: F HIGH Risk → Stable

Red Flags

  • 1 citation(s) at the highest severity level — immediate risk to residents
  • 2 citation(s) where residents suffered actual harm

Green Flags

  • 4-star staffing rating
  • Below-average deficiency count (3 vs 9 state avg)

Quick Facts

★★★☆☆
CMS Overall
★★★☆☆
Health Inspection
3
0.3x state avg
Deficiencies
$23,480
Fines (3-yr)
★★★★☆
Staffing

Violation Timeline

December 18, 2024

3 deficiencyies
F0679 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide activities to meet all resident's needs.

F0760 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

F0880 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

October 7, 2024

1 deficiency
F0689 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

June 20, 2023

6 deficiencyies
F0656 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide care and assistance to perform activities of daily living for any resident who is unable.

F0697 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe, appropriate pain management for a resident who requires such services.

F0880 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0580 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

F0842 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

February 27, 2023

8 deficiencyies
F0607 Potential Harm Scope/Severity: F

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Develop and implement policies and procedures to prevent abuse, neglect, and theft.

F0678 Immediate Jeopardy Scope/Severity: J

Quality of Life and Care Deficiencies

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Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

F0688 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

F0689 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0842 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

F0843 Potential Harm Scope/Severity: F

Administration Deficiencies

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Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

F0867 Potential Harm Scope/Severity: F

Administration Deficiencies

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Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

F0947 Potential Harm Scope/Severity: F

Nursing and Physician Services Deficiencies

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Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

August 28, 2019

2 deficiencyies
F0638 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Assure that each resident’s assessment is updated at least once every 3 months.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

See full violation history →

Staffing

0.91
RN hrs/res/day
0.81
LPN hrs/res/day
2.87
CNA hrs/res/day
4.02
Weekend hrs/res/day
57%
Total nurse turnover
62%
RN turnover

A nurse checks on each resident roughly every 5.2 hours on average.

Fines & Penalties

  • Fine Feb 27, 2023
    $23,480
Total $23,480

Ownership

Non profit - Church related Chain: COVENANT LIVING
  • COVENANT LIVING COMMUNITIES & SERVICES

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 01/26/1988

    100% Organization
  • HOLT, JODY

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 06/02/2017

    Individual
  • BENTLEY, SARAH

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • CHRISTENSEN, PAMELA

    CORPORATE DIRECTOR

    Since since 07/01/2013

    Individual
  • DAVIS, KARA

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • EASTBURG, MARK

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • KINCANNON, KURT

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • MANLOVE, MATT

    CORPORATE DIRECTOR

    Since since 07/01/2017

    Individual
  • MARTIN, ROBERT

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • NELSON, RICHARD

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • OXENDALE, ROGER

    CORPORATE DIRECTOR

    Since since 07/01/2017

    Individual
  • RINARD, DALE

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • VANOVER, ANDREW

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • WENRICH, JOHN

    CORPORATE DIRECTOR

    Since since 07/01/2019

    Individual
  • CUNLIFFE, TERRI

    CORPORATE OFFICER

    Since since 05/22/2015

    Individual
  • ERICKSON, DAVID

    CORPORATE OFFICER

    Since since 01/31/2008

    Individual
  • ERICKSON, REBEKAH

    CORPORATE OFFICER

    Since since 07/01/2019

    Individual
  • HOLT, JODY

    CORPORATE OFFICER

    Since since 06/02/2017

    Individual
  • CUNLIFFE, TERRI

    W-2 MANAGING EMPLOYEE

    Since since 05/22/2015

    Individual
  • HOLT, JODY

    W-2 MANAGING EMPLOYEE

    Since since 06/02/2017

    Individual

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