Inspection Reports for
Amberwood Post Acute
4686 E ASBURY CIR, DENVER, CO, 80222-4723
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of physical abuse involving residents at Amberwood Post Acute.
Complaint Details
The complaint investigation was substantiated. The incident involved Resident #1 physically abusing Resident #2 and Resident #3 by throwing a wheelchair armrest at them after a dispute involving property damage and verbal altercations. The police were called, and no injuries were reported.
Findings
The facility failed to protect two residents from physical abuse by another resident during an altercation involving throwing objects and property damage. No injuries were reported, and the facility took steps including separating residents, notifying authorities, updating care plans, and providing counseling and anger management support.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident.
Report Facts
Residents reviewed for abuse: 5
Residents involved in abuse incident: 3
Frequency of verbal behavioral symptoms: 1
Duration of separation: 72
BIMS scores: 12
BIMS scores: 15
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident behavior and abuse training. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident interactions and abuse incident knowledge. |
| CNA #2 | Certified Nurse Aide | Witnessed the incident and provided details about the altercation. |
| CNA #3 | Certified Nurse Aide | Reported knowledge of the incident and staff interventions. |
| Director of Nursing | Director of Nursing (DON) | Provided facility policy, interviewed residents and staff, and described interventions post-incident. |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Interviewed about resident relationships and staff monitoring. |
Inspection Report
Routine
Deficiencies: 13
Date: Oct 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including personal funds management, discharge processes, PASRR recommendations, pain management, restorative nursing, medication administration, infection control, and ancillary services.
Findings
The facility was found deficient in multiple areas including failure to manage residents' personal funds accounts accurately, inadequate discharge planning and notification, failure to timely initiate PASRR recommended therapies, incomplete pain medication parameters, inconsistent restorative nursing services, medication administration errors, improper storage of medications and treatment carts, failure to provide timely dental and vision services, inadequate infection control practices, and failure to ensure resident hand hygiene before meals.
Deficiencies (13)
Failed to notify Medicaid residents or their representatives when personal funds accounts exceeded eligibility limits.
Failed to provide appropriate discharge process and notification to Resident #76.
Failed to permit Resident #76 to return to the facility after hospital transfer and failed to reassess status.
Failed to incorporate PASRR Level II recommendations timely for Residents #65 and #43.
Failed to ensure PRN pain medications had physician ordered parameters related to pain severity.
Failed to develop and implement a collaborative discharge plan with Resident #182 and notify representative.
Failed to ensure Resident #24's fingernails were trimmed and clean.
Failed to establish a consistent restorative nursing program for Residents #43, #51, and #66 to prevent decline in ADLs.
Failed to implement a plan of care to address risks posed by Resident #65's smoking habit and history of self-inflicted fire injury.
Medication administration observation error rate was 14.63%, including failure to prime insulin pen and incorrect medication administration.
Failed to ensure treatment and medication carts were locked when unattended.
Failed to ensure dental services were provided timely to Residents #18, #32, and #51.
Failed to maintain an infection control program including proper cleaning of resident rooms, assisting residents with hand hygiene before meals, cleaning glucometers appropriately, and proper use of PPE during wound care.
Report Facts
Medication administration error rate: 14.63
Residents reviewed for personal funds accounts: 39
Residents reviewed for discharge: 39
Residents reviewed for PASRR recommendations: 39
Residents reviewed for pain management: 39
Residents reviewed for restorative nursing: 39
Residents reviewed for medication storage: 3
Residents reviewed for dental services: 39
Residents reviewed for infection control: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed medication administration errors including failure to prime insulin pen and improper cleaning of glucometer. |
| HK #1 | Housekeeper | Observed failing to follow proper infection control procedures during cleaning of resident rooms. |
| HK #2 | Housekeeper | Observed failing to follow proper infection control procedures during cleaning of resident rooms. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, restorative nursing, infection control, and ancillary services. |
| SSD | Social Services Director | Interviewed regarding deficiencies in discharge planning, ancillary services, and resident safety. |
| NHA | Nursing Home Administrator | Interviewed regarding overall facility deficiencies and follow-up plans. |
| RCC | Regional Clinical Consultant | Interviewed regarding medication orders, restorative nursing, and ancillary services. |
| LPN #5 | Licensed Practical Nurse | Observed medication administration errors including incorrect dosing of Metamucil. |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding pain medication parameters. |
| WCN | Wound Care Nurse | Observed improper PPE use during wound care. |
| ADON | Assistant Director of Nursing | Observed improper PPE use during wound care and interviewed regarding resident safety. |
| HKS | Housekeeping Supervisor | Interviewed regarding housekeeping training and cleaning procedures. |
| MDSC | MDS Coordinator | Interviewed regarding restorative nursing documentation. |
| RNAS | Restorative Program Supervisor | Interviewed regarding restorative nursing program compliance. |
Inspection Report
Routine
Deficiencies: 12
Date: May 18, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident participation in care planning, inadequate accommodation of resident needs, unresolved grievances, incomplete care plans, failure to maintain residents' abilities, inconsistent personal care, medication errors, improper medication storage, inadequate infection control practices, and lack of a water management program for Legionella.
Deficiencies (12)
Failed to ensure one resident (#72) had the right to participate in the development and implementation of his or her person-centered plan of care.
Failed to reasonably accommodate the needs and preferences of residents #21 and #54, including failure to install a transfer pole and provide a suitable call light device.
Failed to make prompt efforts to resolve a grievance for resident #60 regarding missing personal identification documents.
Failed to develop a comprehensive care plan including measurable objectives for residents #29 and #21, including bed height preference and IV antibiotic therapy.
Failed to ensure resident #61 had access to a whiteboard for communication needs.
Failed to provide consistent showers and nail care for residents #2 and #71 according to their preferences and plans of care.
Failed to investigate, determine origin, and monitor a bruise on resident #40's wrist.
Failed to ensure physician orders for supplemental oxygen for residents #83 and #187, and failed to provide correct oxygen flow for resident #24.
Failed to assess, obtain consent, and maintain bed cane safety for resident #51.
Failed to discard prepared medications not administered, maintain medication storage room cleanliness, and discard expired medications.
Failed to maintain an infection control program including proper disinfectant dwell times, cleaning of resident rooms, hand hygiene, and water management for Legionella.
Failed to ensure resident #39 was administered an accurate dose of cholecalciferol (Vitamin D) medication, resulting in daily dosing instead of weekly.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Expired medication: 1
Medication error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding skin assessment and oxygen orders |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding bed cane safety and medication orders |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication cart and expired medication |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding shower refusals and medication administration |
| CNA #1 | Certified Nurse Aide | Interviewed regarding bed cane use and safety |
| CNA #4 | Certified Nurse Aide | Interviewed regarding skin discoloration and shower care |
| CNA #5 | Certified Nurse Aide | Interviewed regarding communication with Resident #61 |
| CNA #6 | Certified Nurse Aide | Interviewed regarding skin discoloration |
| CNA #7 | Certified Nurse Aide | Interviewed regarding shower and nail care for Resident #71 |
| HSK #1 | Housekeeper | Observed and interviewed regarding cleaning practices |
| HSKD | Housekeeping Director | Interviewed regarding cleaning practices and training |
| MTD | Maintenance Director | Interviewed regarding bed cane installation and water management program |
| DON | Director of Nursing | Interviewed regarding multiple care and policy issues |
| NHA | Nursing Home Administrator | Provided policies and interviewed regarding facility practices |
| MD | Medical Director | Interviewed regarding Vitamin D medication error |
| Pharmacist | Interviewed regarding Vitamin D medication order and error | |
| ADON | Assistant Director of Nursing | Interviewed regarding medication disposal and bed cane safety |
| DTS | Director of Therapy Services | Interviewed regarding therapy and transfer pole installation |
| SSD | Social Services Director | Interviewed regarding grievances and care conferences |
| AD | Activities Director | Interviewed regarding communication needs of Resident #61 |
| AA | Activities Assistant | Interviewed regarding communication with Resident #61 |
Inspection Report
Deficiencies: 1
Date: Apr 3, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing appropriate restorative nursing care, specifically to assess whether Resident #1 received active and passive range of motion (ROM) as indicated by the comprehensive care plan.
Findings
The facility failed to provide the appropriate treatment and services to maintain or improve the abilities of Resident #1, who did not receive any documented restorative nursing visits for active or passive range of motion despite care plan requirements. Staff interviews confirmed lack of documentation and restorative care provision, with the facility acknowledging the need for immediate corrective action.
Deficiencies (1)
Failure to provide Resident #1 with active and passive range of motion (ROM) as indicated by the comprehensive care plan.
Report Facts
Restorative nursing program minutes: 0
Restorative nursing program frequency: 3
Restorative nursing program frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Provided facility restorative nursing services policy and interviewed regarding restorative program and documentation for Resident #1. |
| Director of Nursing | DON | Interviewed regarding Resident #1's restorative care and importance of ROM exercises. |
| Certified Nurse Aide #1 | CNA | Interviewed about restorative exercise documentation and care provided to Resident #1. |
| Nursing Home Administrator | NHA | Interviewed about restorative program documentation and follow-up with prior facility ownership. |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of significant changes, inadequate assistance with activities of daily living, failure to provide consistent restorative nursing services, inadequate fall prevention and assessment, improper nephrostomy care without physician orders, serving food at improper temperatures and poor palatability, failure to assist residents with hand hygiene, and improper food storage and sanitation in resident unit refrigerators.
Deficiencies (8)
Failure to immediately notify resident representatives of significant changes in condition or hospital transfers for two residents.
Failure to provide timely incontinent care, repositioning, and meal assistance for two residents dependent on staff.
Failure to provide consistent restorative nursing services including splinting and passive range of motion as prescribed for one resident.
Failure to prevent falls and adequately assess injuries and implement interventions after falls for two residents, resulting in actual harm including head injury.
Failure to ensure appropriate nephrostomy care with physician orders and care plans for one resident.
Failure to serve food that is palatable, at proper temperature, and with appropriate utensils; use of styrofoam containers and plastic utensils negatively impacted food quality.
Failure to assist or encourage residents to perform hand hygiene before and after meals in dining and room service settings.
Failure to maintain sanitary conditions in resident unit refrigerators including cleaning, dating, labeling, and discarding expired food items.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #4 | Licensed Practical Nurse | Interviewed regarding failure to notify family and nephrostomy care |
| Certified nurse aide #6 | Certified Nurse Aide | Interviewed regarding failure to assist with incontinent care, meal assistance, and hand hygiene |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding fall assessments and notification failures |
| Corporate Nurse Consultant (CNC) | Corporate Nurse Consultant | Provided facility policies and interviewed regarding restorative services and nephrostomy care |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding food temperature, use of styrofoam, and unit refrigerator maintenance |
| Registered Dietitian (RD) | Registered Dietitian | Interviewed regarding food temperature and unit refrigerator maintenance |
| Director of Therapy (DOT) | Director of Therapy | Interviewed regarding restorative nursing services and fall prevention |
Viewing
Loading inspection reports...
