Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage policies and procedures, specifically ensuring that medications and biologicals are stored and locked according to accepted professional standards.
Findings
The facility failed to ensure that one of three medication carts was locked when unattended and not in the direct line of sight of a nurse. Observations and staff interviews confirmed that medication cart #5 was left unlocked and unattended in a high traffic area, contrary to facility policy.
Deficiencies (1)
Medication cart #5 was left unlocked and unattended, failing to comply with medication storage policy requiring locked medication carts.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed unlocking and locking medication cart #5 and confirmed it was not locked correctly. |
| RN #3 | Registered Nurse | Observed leaving medication cart #5 unlocked and later locking it; interviewed regarding medication cart locking. |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication cart locking policy and importance. |
| Director of Nursing | Director of Nursing | Provided facility medication storage policy and interviewed regarding medication cart locking requirements. |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, medication storage, infection prevention and control, and overall facility operations.
Findings
The facility failed to develop comprehensive care plans addressing residents' pressure ulcers, feeding tube changes, IV antibiotics, and fall interventions for three residents. Medication storage deficiencies included discontinued medications not discarded, loose pills in medication carts, and inadequate refrigerator temperature monitoring. Infection control lapses involved failure to offer hand hygiene to residents before meals and improper handling of point of care testing supplies, risking cross-contamination.
Deficiencies (3)
Failed to develop comprehensive care plans addressing pressure ulcers, feeding tube changes, IV antibiotics, and fall interventions for residents #4, #11, and #26.
Failed to ensure proper medication storage including discarding discontinued medications, removing loose pills, and monitoring refrigerator temperatures.
Failed to provide and implement an infection prevention and control program including offering hand hygiene before meals and preventing contamination of point of care testing supplies.
Report Facts
Residents affected: 3
Missing temperature log days: 44
Loose pills found: 4
Staff education signatures: 10
Residents observed in dining room: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication storage deficiencies and resident #4 wound care interview. |
| Director of Rehabilitation | DOR | Interviewed regarding resident #4's care plan and interventions. |
| Infection Preventionist #2 | Wound Care Nurse | Interviewed about resident #4's pressure injury care plan. |
| Certified Nurse Aide #5 | CNA | Interviewed about fall risk and interventions for resident #11. |
| Registered Dietitian | RD | Interviewed about nutrition care plan updates for resident #11. |
| Director of Nursing | DON | Interviewed multiple times regarding care plan updates, medication storage, infection control, and staff education. |
| LPN #2 | Licensed Practical Nurse | Interviewed and educated regarding improper use of point of care testing supplies. |
| Certified Nurse Aide #1 | CNA | Interviewed about failure to offer hand hygiene to residents before meals. |
| Certified Nurse Aide #2 | CNA | Interviewed about failure to offer hand hygiene to residents before meals. |
| Registered Nurse #1 | RN | Interviewed about medication refrigerator temperature monitoring. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 2
Date: May 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #7, focusing on the facility's failure to provide adequate supervision and proper transfer procedures to prevent accidents.
Complaint Details
The complaint investigation focused on Resident #7's fall on 3/6/23 during transfer from bed to wheelchair with only one staff member assisting, contrary to care plan requiring two-person assistance. The fall resulted in a head laceration requiring two sutures and hospital admission. Interviews with Resident #7, her son, and staff confirmed the failure to follow proper transfer protocols and lack of staff education post-fall.
Findings
The facility failed to ensure proper two-person assistance during resident transfers, resulting in Resident #7 falling and sustaining a head laceration requiring hospital treatment. Additionally, the facility failed to provide proper transfer education to staff post-incident and did not maintain an effective infection prevention and control program, including inadequate surface disinfection and hand hygiene practices.
Deficiencies (2)
Failure to provide adequate supervision and two-person assistance during transfers, leading to a fall with injury for Resident #7.
Failure to maintain an infection prevention and control program, including improper surface disinfectant time, inadequate cleaning of resident rooms, and improper hand hygiene.
Report Facts
Residents reviewed: 27
Residents affected: 1
Fall risk score: 7
Sutures required: 2
Fall dates: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged failure to implement two-person assistance and lack of transfer education post-fall |
| Certified Nurse Aide | CNA | Received disciplinary action for failure to provide two-person assistance during Resident #7's transfer |
| Transition Nurse | Transition Nurse (TR) | Assisted Resident #7 during recliner incident and provided verbal education only |
| Physical Therapist Assistant | PTA | Confirmed transfer status communication and two-person assistance requirement |
| Housekeeper #1 | Housekeeper | Observed failing to follow proper disinfection procedures and hand hygiene |
| Housekeeper #2 | Housekeeper | Observed failing to follow proper disinfection procedures and hand hygiene |
| Licensed Practical Nurse #1 | LPN | Observed not meeting minimum handwashing time during medication administration |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 27, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards for residents, specifically focusing on the care provided to Resident #32 regarding oxygen therapy and related procedures.
Findings
The facility failed to provide safe and appropriate respiratory care for Resident #32 by not marking oxygen tubing and humidifier bottles with dates and initials, not maintaining water in the oxygen humidifier bottle, lacking complete oxygen orders including flow amounts, and having an incomplete oxygen care plan. Staff education was provided after deficiencies were identified.
Deficiencies (5)
Oxygen tubing was not marked with date and initial when replaced per physician orders.
Oxygen humidifier bottle was not marked with date and initial when replaced per physician orders.
Oxygen humidifier bottle was empty of sterile water to prevent nasal dryness and per physician orders.
Incomplete oxygen orders lacking baseline liter flow amount and frequency.
Incomplete comprehensive oxygen care plan missing safe handling, humidification, cleaning, storage, dispensing, and infection control practices.
Report Facts
Residents reviewed for respiratory care: 3
Residents affected: 1
Oxygen liter per minute settings observed: 3
Oxygen liter per minute settings observed: 2.5
Staff educated on oxygen care: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding oxygen settings and care procedures |
| RN #2 | Registered Nurse | Documented oxygen tubing and humidifier bottle changes but did not initial or date them; received education on 1/27/22 |
| DON | Director of Nursing | Interviewed multiple times regarding oxygen care deficiencies and staff education |
| NHA | Nursing Home Administrator | Interviewed regarding facility policy expectations on oxygen care |
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