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)
11.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
121% 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: 16
Date: Oct 15, 2024
Visit Reason
Routine state inspection of Amberwood Post Acute nursing home to assess compliance with regulatory requirements including resident care, safety, infection control, medication administration, and ancillary services.
Findings
The facility had multiple deficiencies including failure to manage residents' personal funds accounts accurately, inadequate discharge planning and notification, failure to provide timely behavioral health and dental services, incomplete restorative nursing programs, medication administration errors, unlocked medication and treatment carts, improper infection control practices, and inadequate supervision of a resident with a history of self-inflicted burns and smoking.
Deficiencies (16)
F 0569: Facility failed to notify Medicaid-funded residents or their representatives when personal funds accounts exceeded eligibility limits.
F 0622: Facility failed to provide Resident #76 with appropriate discharge process and notice, and did not permit return after hospital transfer.
F 0626: Facility failed to permit Resident #76 to return to the nursing home after hospitalization and did not reassess or document discharge plan.
F 0644: Facility failed to incorporate PASRR Level II recommendations and timely initiate behavioral health therapy for Residents #43 and #65.
F 0658: Facility failed to ensure PRN pain medications for Resident #15 had physician-ordered parameters for pain severity and medication strength.
F 0660: Facility failed to develop and implement a collaborative discharge plan and provide proper discharge notifications for Resident #182.
F 0677: Facility failed to ensure Resident #24 received necessary assistance with activities of daily living including fingernail care.
F 0684: Facility failed to ensure timely physician orders and provision of lymphedema leg wraps for Resident #51.
F 0685: Facility failed to arrange timely optometry services for Resident #18 and document referrals for vision care.
F 0688: Facility failed to establish a consistent restorative nursing program and document restorative services for Residents #43, #51, and #66.
F 0689: Facility failed to provide adequate supervision to Resident #65 who smoked independently despite history of self-inflicted burns and fire risk.
F 0759: Medication administration observation error rate was 14.63%, including failure to prime insulin pen and incorrect medication doses.
F 0760: Facility failed to ensure insulin pen was primed prior to administration for Resident #3.
F 0761: Treatment and medication carts were found unlocked and unattended multiple times posing safety risks.
F 0791: Facility failed to provide or obtain dental services timely for Residents #18, #32, and #51.
F 0880: Facility failed to maintain infection control program including improper cleaning of resident rooms, failure to assist residents with hand hygiene before meals, improper cleaning of glucometers, and improper PPE use during wound care.
Report Facts
Medication administration error rate: 14.63
Residents reviewed: 39
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration errors including failure to prime insulin pen and improper cleaning of glucometer |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, restorative program, infection control, and discharge planning |
| SSD | Social Services Director | Interviewed regarding discharge planning, behavioral health referrals, ancillary services, and resident supervision |
| NHA | Nursing Home Administrator | Interviewed regarding overall facility compliance and follow-up on deficiencies |
| HK #1 | Housekeeper | Observed and interviewed regarding improper cleaning and infection control practices |
| HK #2 | Housekeeper | Observed and interviewed regarding improper cleaning and infection control practices |
| RNAS | Restorative Program Supervisor | Interviewed regarding restorative nursing program deficiencies |
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
Complaint Investigation
Deficiencies: 1
Date: Apr 3, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate restorative nursing care, specifically active and passive range of motion (ROM) exercises, to Resident #1 as indicated in the care plan.
Complaint Details
The complaint investigation found that Resident #1, with quadriplegia and traumatic brain injury, did not receive the restorative nursing program or exercise services as required. The complaint was substantiated based on interviews, record reviews, and lack of documentation.
Findings
The facility failed to provide Resident #1 with the restorative nursing program including active and passive range of motion exercises as required by the care plan. Documentation showed no restorative nursing visits or exercise minutes for Resident #1 for nearly a year, and staff interviews confirmed lack of restorative care delivery.
Deficiencies (1)
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion (ROM) and mobility for Resident #1 as required by the comprehensive care plan. There was no documentation or evidence that Resident #1 received active or passive ROM exercises during the review period.
Report Facts
Restorative nursing program minutes: 0
Frequency of AROM: 3
Duration of AROM: 15
Duration of PROM: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided facility restorative nursing policy and was interviewed regarding restorative program documentation and corrective actions. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about Resident #1's restorative care and importance of ROM exercises. |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed about restorative exercise documentation and care provided to Resident #1. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed about prior facility ownership and restorative program documentation follow-up. |
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 |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Feb 15, 2022
Visit Reason
The inspection was conducted to investigate complaints related to failure to notify resident representatives of significant changes, failure to provide adequate care for activities of daily living, failure to prevent falls, and other care deficiencies.
Complaint Details
The complaint investigation focused on failures to notify resident representatives of significant changes, inadequate care for activities of daily living, failure to prevent falls and assess injuries, inadequate restorative nursing services, improper nephrostomy care, and food service issues including temperature and sanitation.
Findings
The facility failed to notify resident representatives of significant changes in condition, failed to provide adequate assistance with activities of daily living including incontinent care and meal positioning, failed to provide consistent restorative nursing services, failed to prevent falls resulting in injury, failed to provide appropriate nephrostomy care, and failed to ensure food was served at proper temperature and under sanitary conditions.
Deficiencies (7)
F580: The facility failed to immediately notify resident representatives of significant changes in condition for two residents, including hospitalization and falls with potential injury.
F677: The facility failed to provide timely incontinent care, repositioning, and meal positioning assistance for two residents dependent on staff for activities of daily living.
F688: The facility failed to provide consistent restorative nursing services including passive range of motion and splinting for a resident with limited mobility and contractures.
F689: The facility failed to prevent falls and adequately assess and intervene after falls for two residents, resulting in actual harm including a subdural hemorrhage.
F690: The facility failed to provide appropriate nephrostomy care with physician orders and care plans for a resident with nephrostomy tubes.
F804: The facility failed to ensure food was palatable, served at proper temperature, and served in appropriate containers, resulting in cold and unappetizing meals.
F812: The facility failed to ensure residents were assisted or encouraged to perform hand hygiene before and after meals and failed to maintain sanitary conditions in resident unit refrigerators.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 5
Food temperature: 103
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 incontinent care and restorative nursing services |
| Director of Nursing | Director of Nursing | Interviewed regarding fall assessments and notification failures |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and unit refrigerator sanitation |
| Registered Dietitian | Registered Dietitian | Interviewed regarding food temperature and unit refrigerator sanitation |
| Director of Therapy | Director of Therapy | Interviewed regarding restorative nursing services and fall risk |
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