Inspection Reports for
Center at Lowry, LLC
8550 E LOWRY BLVD, DENVER, CO, 80230-6932
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Dec 10, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care and proper notification procedures following changes in resident conditions, medication administration, and wound care management.
Findings
The facility failed to notify a resident's physician promptly after a significant change in condition (slurred speech) and failed to follow physician's orders for medication and wound care for multiple residents. Several wound treatments were provided without physician orders, and documentation and communication deficiencies were noted.
Deficiencies (4)
Failure to notify the physician of a resident's significant change in condition (slurred speech) in a timely manner.
Failure to follow physician's orders for Resident #1's anti-fungal medication.
Failure to follow physician's orders for Resident #3's skin treatment.
Providing skin treatment to Residents #2 and #4 without physician's orders.
Report Facts
Residents in sample: 12
Residents affected by notification deficiency: 1
Residents affected by medication/wound care deficiencies: 4
Dates of medication non-administration: 6
Dates of wound care without physician orders: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Assessed Resident #1 on 10/18/25 and notified ADON about slurred speech |
| ADON | Assistant Director of Nursing | Completed assessment on Resident #1 and instructed RN #1 to notify physician |
| DON | Director of Nursing | Interviewed regarding notification procedures and wound care order documentation |
| WCN #1 | Wound Care Nurse | Provided wound care and documented skin assessments; delayed entry of physician orders |
| LPN #1 | Licensed Practical Nurse | Provided wound care to Resident #4's left leg and noted incomplete treatment on right leg |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 15, 2025
Visit Reason
The inspection was conducted following a complaint investigation triggered by an elopement incident involving Resident #1 who left the facility unescorted and was found injured outside the premises.
Complaint Details
The complaint investigation was substantiated. Resident #1 eloped on 6/22/25, was found by police with injuries, and was hospitalized. The facility failed to identify exit-seeking behavior and implement effective interventions prior to the incident.
Findings
The facility failed to identify Resident #1 as at risk for elopement and did not provide adequate supervision to prevent the resident from leaving the facility, resulting in actual harm. The facility implemented a plan of correction prior to the onsite investigation.
Deficiencies (1)
Failed to ensure residents received adequate supervision to prevent accidents, specifically failure to identify and prevent Resident #1's elopement.
Report Facts
Residents reviewed for accidents: 3
Residents affected: 1
Date of elopement incident: Jun 22, 2025
Date of survey completion: Jul 15, 2025
Date of staff education completion: Jun 26, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided plan of correction and interviewed regarding the elopement incident and corrective actions |
| Director of Nursing | DON | Interviewed about lack of awareness of Resident #1's exit-seeking behavior and supervision failures |
| Assistant Director of Nursing | ADON | Notified about Resident #1's elopement and involved in search and reporting |
| Certified Nurse Aide #1 | CNA | Interviewed about Resident #1's wandering behavior and supervision |
| Registered Nurse #1 | RN | Interviewed about Resident #1's admission status and supervision |
| Registered Nurse #2 | RN | Interviewed about Resident #1's status on day of elopement and search efforts |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, infection control, food safety, and facility sanitation.
Findings
The facility was found deficient in multiple areas including failure to provide access to updated survey results, untimely insulin administration, improper medication storage, inadequate food sanitation practices leading to immediate jeopardy, improper infection control practices including PPE use, and failure to clean insulin pens prior to use.
Deficiencies (5)
Failed to ensure residents and representatives had full access to the facility's most recent survey findings including survey results, certifications, complaint investigations, and plans of correction.
Failed to administer insulin timely per physician orders for two residents.
Failed to ensure medications and biologicals were stored and labeled properly; nursing staff stored medications in their pockets.
Failed to ensure cookware, drinkware, dishware, and flatware were sufficiently sanitized; dishwashing machine malfunctioned leading to immediate jeopardy to resident health or safety.
Failed to maintain proper infection prevention and control program including improper PPE use, failure to clean insulin pens prior to administration, and failure to prevent cross contamination from COVID-19 positive resident rooms.
Report Facts
Insulin administration late times: 12
Insulin administration late times: 8
Dishwashing machine log missing entries: 100
Dishwashing machine log missing days: 15
Dishwashing machine sanitizer PPM: 0
Dishwashing machine sanitizer PPM: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to clean the rubber seal of insulin pens prior to administration; unaware of cleaning requirement |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding insulin administration timing and effects |
| RN #1 | Registered Nurse | Interviewed regarding insulin administration timing and effects |
| DON | Director of Nursing | Interviewed regarding insulin administration timing, medication storage, infection control, and dishwashing machine monitoring |
| DM | Dietary Manager | Reported dishwashing machine issues, sanitizer PPM readings, and staff training |
| DA #1 | Dietary Aide | Observed using improper three-compartment sink sanitizing method |
| DA #3 | Dietary Aide | Observed warming bread rolls with soiled gloves |
| IP | Infection Preventionist | Interviewed regarding infection control practices and PPE use |
| NHA | Nursing Home Administrator | Interviewed regarding survey binder availability, dishwashing machine issues, and infection control |
| RD | Registered Dietitian | Interviewed regarding dishwashing and infection control practices |
| CNA #1 | Certified Nurse Aide | Observed failing to offer PPE to visitor entering COVID-19 positive resident room |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication errors affecting Resident #15, specifically concerning the administration and dosing of prescribed diuretic medication.
Complaint Details
The complaint investigation found that Resident #15 experienced significant medication errors including incorrect transcription of medication orders, missed doses, and incorrect dosing. The errors were substantiated by record reviews and interviews, with the pharmacist identifying the initial transcription error on 8/14/23 and the survey identifying ongoing documentation errors on 9/7/23.
Findings
The facility failed to ensure Resident #15 received all doses and the correct dose of prescribed Torsemide medication. Errors included incorrect transcription of medication orders, missed doses, and administration of a higher dose than ordered. The errors were identified during a pharmacist's post-admission review and survey, with corrective actions initiated including staff education and order clarification.
Deficiencies (2)
Failure to ensure Resident #15 received all doses of prescribed diuretic medication.
Failure to ensure Resident #15 received the correct dose of the diuretic medication.
Report Facts
Residents in sample: 12
Residents affected: 1
Dose of Torsemide: 20
Dose of Torsemide: 40
Missed dose date: 1
Medication administration period: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication errors and corrective actions |
| Physician's Assistant | Physician's Assistant (PA) | Documented medication orders and involved in order clarification |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident work choice, protection of resident belongings, notification of hospital transfers, bed-hold policy, and assistance with activities of daily living.
Findings
The facility was found deficient in multiple areas including failure to ensure proper assessment and physician orders for medication self-administration, requiring residents or families to perform laundry services, misappropriation of a resident's personal belongings, failure to provide written notification of hospital transfers and bed-hold policies, and inadequate assistance with grooming activities such as shaving facial hair.
Deficiencies (6)
Failed to ensure assessment and physician order before allowing resident to self-administer medications.
Failed to allow residents to choose whether to perform laundry services; required families to launder resident clothing.
Failed to protect resident from misappropriation of personal belongings by giving belongings to an unidentified visitor without permission.
Failed to provide written notification to resident and representative before hospital transfer and failed to notify ombudsman.
Failed to provide written information regarding bed-hold policy to resident and representative upon hospital transfer.
Failed to regularly offer trimming or shaving of facial hair to a resident requiring extensive assistance with personal hygiene.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
BIMS score: 15
BIMS score: 13
BIMS score: 15
BIMS score: 15
BIMS score: 15
Facial hair length: 1
Shaving refusals: 6
Shaving not done: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | RN | Stated nurse should remain with resident during medication administration; Resident #14 not safe to self-administer |
| Registered Nurse #3 | RN | Left pills on bedside table; acknowledged should have stayed with Resident #14 |
| Physician's Assistant | PA | Stated Resident #14 needed assessment and training for self-administration |
| Director of Nursing | DON | Stated nurse should stay with resident during medication administration; Resident #14 not safe to self-administer; commented on laundry and shaving policies |
| Executive Director | ED | Stated nurse should stay with resident during medication administration; commented on laundry and belongings policies |
| Certified Nursing Assistant #1 | CNA | Stated families did residents' laundry; provided gowns if no clean clothes |
| Certified Nursing Assistant #2 | CNA | Confirmed no in-house laundry; families responsible for laundry |
| Certified Nursing Assistant #3 | CNA | Responsible for trimming facial hair; acknowledged failure to offer shaving to Resident #38 |
| Licensed Practical Nurse #1 | LPN | Acknowledged CNAs responsible for shaving; did not offer shaving to Resident #38 |
| Licensed Practical Nurse #2 | LPN | Stated facility staff did not provide written notification of hospital transfer or bed-hold policy |
| Social Worker | SW | Gave Resident #105's belongings to unidentified visitor without permission |
| Business Office Manager | BOM | Stated residents/families responsible for personal laundry; facility did not charge for laundry |
| Administrator | ADM | Commented on hospital transfer notification and shaving policies |
| Assistant Director of Nursing | ADON | Stated staff should immediately offer shaving to residents with visible facial hair |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 13, 2021
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on compliance with hand hygiene, housekeeping cleaning procedures, and disinfection of shared equipment in the COVID-19 recovery unit.
Findings
The facility failed to maintain an effective infection prevention and control program, with observed breaches in hand hygiene practices, improper cleaning sequences by housekeeping, and inadequate disinfection of shared equipment. Training was provided following the findings, and the facility was not in COVID-19 outbreak status at the time of inspection.
Deficiencies (3)
Failure to ensure staff followed proper hand hygiene practices with glove changes
Failure to ensure housekeeping cleaning steps included starting from clean to dirty
Failure to clean and disinfect shared equipment/products
Report Facts
Staff vaccination rate: 66
Resident vaccination rate: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Services Director | Housekeeping Supervisor | Named in relation to cleaning procedure deficiencies |
| Maintenance Services Director | Maintenance Services Director | Named in relation to housekeeping supervision and equipment replacement |
| Licensed Practical Nurse #1 | LPN | Named in relation to medication cart and hand hygiene observations |
| Certified Nurse Aide #1 | CNA | Named in relation to hand hygiene and resident care observations |
| Licensed Practical Nurse #3 | LPN | Named in relation to medication administration and infection control observations |
| Certified Nurse Aide #2 | CNA | Named in relation to resident oral care and repositioning |
| Nursing Home Administrator | NHA | Named in relation to interviews and training follow-up |
| Infection Preventionist | IP | Named in relation to infection control monitoring and training |
| Minimum Data Set Coordinator | MDSC | Named in relation to infection data collection |
| Director of Nursing | DON | Named in relation to infection control oversight |
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