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)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 2
Date: Dec 10, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify a physician of a resident's change in condition and failure to follow physician's orders for medication and wound care treatments.
Complaint Details
The complaint investigation substantiated that the facility did not notify the physician timely about Resident #1's slurred speech and failed to follow physician's orders for medication and wound care for multiple residents.
Findings
The facility failed to notify the physician promptly about a resident's episode of slurred speech and failed to follow physician's orders for medication and wound care for multiple residents. Wound treatments were provided without physician orders for some residents, and documentation of medication administration was incomplete.
Deficiencies (2)
F 0580: The facility failed to notify the physician of Resident #1's episode of slurred speech on 10/18/25 until 10/22/25, delaying medical intervention.
F 0658: The facility failed to follow physician's orders for Resident #1's anti-fungal medication and Resident #3's skin treatment, and provided wound care to Residents #2 and #4 without physician orders.
Report Facts
Sample residents: 12
Residents affected: 4
Residents affected: 1
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 orders |
| WCN #1 | Wound Care Nurse | Provided wound care and documented physician orders for multiple residents |
| LPN #1 | Licensed Practical Nurse | Provided wound care to Resident #4's left leg and reported incomplete treatment on right leg |
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
Deficiencies: 1
Date: Jul 15, 2025
Visit Reason
The inspection was conducted to investigate a deficiency related to the facility's failure to ensure adequate supervision to prevent accidents, specifically focusing on an elopement incident involving a resident.
Findings
The facility failed to identify a resident at risk for elopement and did not provide adequate supervision to prevent the resident from leaving the facility unescorted, resulting in injury. The facility implemented a plan of correction including staff education, updated care plans, and monitoring to prevent future elopements.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in actual harm to a resident who eloped and was injured.
Report Facts
Residents reviewed for accidents: 3
Residents affected: 1
Dates related to events: Jun 18, 2025
Dates related to events: Jun 22, 2025
Dates related to events: Jun 26, 2025
Dates related to events: Jul 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided the plan of correction and was interviewed regarding the elopement incident and corrective actions. |
| Director of Nursing | DON | Interviewed about the lack of awareness of resident's exit seeking behavior and supervision failures. |
| Assistant Director of Nursing | ADON | Notified about the resident's elopement and involved in the search and notification process. |
| Certified Nurse Aide #1 | CNA | Interviewed about resident's wandering behavior and supervision prior to elopement. |
| Registered Nurse #1 | RN | Interviewed about resident's admission status and supervision. |
| Registered Nurse #2 | RN | Interviewed about the elopement event and staff response. |
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
Complaint Investigation
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted based on complaint investigations and observations related to medication administration, infection control, food sanitation, and regulatory compliance issues at the nursing home.
Complaint Details
The visit was complaint-related, triggered by concerns about medication administration, infection control, and food sanitation. The complaint investigation found substantiated deficiencies in these areas.
Findings
The facility failed to ensure residents and representatives had access to updated survey findings, timely administration of insulin per physician orders, proper medication storage, adequate food sanitation, proper infection prevention practices including PPE use, and proper cleaning of insulin pens. Multiple deficiencies were identified in medication administration, infection control, and food safety.
Deficiencies (5)
F 0577: The facility 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.
F 0684: The facility failed to administer insulin timely per physician orders for two residents, resulting in potential harm due to elevated blood sugar levels.
F 0761: The facility failed to ensure medications and biologicals were stored and labeled properly; nursing staff stored medications in their pockets.
F 0812: The facility failed to ensure food was prepared, distributed, and served under sanitary conditions, including failure of the dishwashing machine, improper sanitization of dishes, and poor hand hygiene and glove use by kitchen staff.
F 0880: The facility failed to maintain an infection control program, including improper cleaning of insulin pen rubber seals, improper PPE use by staff and visitors, and failure to prevent cross-contamination from COVID-19 positive resident rooms.
Report Facts
Residents in sample: 43
Insulin administration late occurrences: 12
Insulin administration late occurrences: 11
Dishwashing log missing entries: 100
Dishwashing log missing days: 15
Glove contamination observations: 32
Glove contamination observations: 7
Cook touched meat with gloves: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed failing to clean insulin pen rubber seal prior to administration |
| LPN #3 | Licensed Practical Nurse | Interviewed about insulin administration timing and blood sugar control |
| LPN #4 | Licensed Practical Nurse | Observed storing medications in pocket; interviewed about PPE and infection control |
| DA #1 | Dietary Aide | Interviewed about dishwashing and three-compartment sink use |
| DA #2 | Dietary Aide | Interviewed about dishwashing and three-compartment sink use |
| DA #3 | Dietary Aide | Observed and interviewed about glove use and food handling |
| DM | Dietary Manager | Interviewed about dishwashing machine issues and staff training |
| RD | Registered Dietitian | Interviewed about dishwashing and infection control |
| IP | Infection Preventionist | Interviewed about infection control practices and PPE use |
| DON | Director of Nursing | Interviewed about infection control and medication administration |
| NHA | Nursing Home Administrator | Interviewed about survey binder access and infection control |
| RN #2 | Registered Nurse | Interviewed about PPE use for COVID-19 positive residents |
| CNA #1 | Certified Nurse Aide | Observed failing to offer PPE to visitor and improper PPE use |
| CNA #2 | Certified Nurse Aide | Observed improper PPE donning |
| ADON | Assistant Director of Nursing | Interviewed about insulin pen cleaning |
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
Complaint Investigation
Deficiencies: 1
Date: Sep 7, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding medication errors affecting residents at the facility.
Complaint Details
The complaint investigation found that one of three sampled residents experienced significant medication errors. The errors included incorrect transcription of medication orders, missed doses, and incorrect dosing frequency and amount. The medication errors were identified during a pharmacist's post-admission review and during the survey.
Findings
The facility failed to ensure that Resident #15 received all doses and the correct dose of prescribed diuretic medication. Multiple medication transcription and documentation errors were identified, resulting in the resident receiving twice the prescribed dose and missing doses.
Deficiencies (1)
F 0760: The facility failed to ensure Resident #15 received all doses of prescribed diuretic medication and the correct dose. Medication transcription errors led to missed doses and incorrect dosing.
Report Facts
Residents sampled: 12
Residents affected: 1
Medication dose: 20
Medication dose: 40
Date of survey: Sep 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication errors and corrective actions | |
| Physician's Assistant | Documented medication orders and involved in clarifying dosing |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, resident rights, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to properly assess and order medication self-administration, requiring residents or families to perform laundry services, misappropriation of resident belongings, failure to provide written notification of hospital transfers and bed-hold policies, and inadequate assistance with grooming for residents requiring help.
Deficiencies (6)
F 0554: The facility failed to ensure an interdisciplinary team assessment and physician order were obtained before allowing a resident to self-administer medications.
F 0566: The facility required residents or their families to perform laundry services for which the facility was responsible, limiting residents' choice.
F 0602: The facility failed to prevent misappropriation of a resident's personal belongings by allowing a Social Worker to release belongings without verifying identity or permission.
F 0623: The facility failed to provide written notification to a resident and their representative and the long-term care ombudsman regarding hospital transfers.
F 0625: The facility failed to provide written information regarding the bed-hold policy to a resident and their representative upon hospital transfer.
F 0677: The facility failed to regularly offer shaving or trimming 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
Shaving refusals: 6
Shaving not offered: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication self-administration finding |
| RN #3 | Registered Nurse | Named in medication self-administration finding |
| Physician's Assistant | Physician's Assistant | Named in medication self-administration finding |
| Director of Nursing | Director of Nursing | Named in medication self-administration and hospital transfer findings |
| Executive Director | Executive Director | Named in medication self-administration, misappropriation, and hospital transfer findings |
| Social Worker | Social Worker | Named in misappropriation of belongings finding |
| CNA #1 | Certified Nursing Assistant | Named in laundry services finding |
| CNA #2 | Certified Nursing Assistant | Named in laundry services finding |
| CNA #3 | Certified Nursing Assistant | Named in grooming assistance finding |
| LPN #1 | Licensed Practical Nurse | Named in grooming assistance finding |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in grooming assistance finding |
| Administrator | Administrator | Named in hospital transfer and grooming assistance findings |
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: 1
Date: Jul 13, 2021
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on compliance with hand hygiene, cleaning procedures, and disinfection of shared equipment in a COVID-19 recovery unit.
Findings
The facility failed to maintain an effective infection prevention and control program, with observed lapses in hand hygiene practices, improper cleaning sequences, and inadequate disinfection of shared equipment. Training was provided following the findings to address these issues.
Deficiencies (1)
F 0880: The facility failed to ensure staff followed proper hand hygiene practices with glove changes, maintain cleaning steps from clean to dirty, and properly clean and disinfect shared equipment and products.
Report Facts
Resident vaccination rate: 71
Staff vaccination rate: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Services Director | Housekeeping Supervisor | Observed and described cleaning practices and use of disinfectants. |
| Maintenance Services Director | Maintenance Services Director | Managed housekeeping department and provided training to housekeeping staff. |
| Licensed Practical Nurse #1 | LPN | Observed during medication administration and infection control practices. |
| Certified Nurse Aide #1 | CNA | Observed during resident care and hand hygiene practices. |
| Licensed Practical Nurse #3 | LPN | Observed drawing up medications and infection control practices. |
| Certified Nurse Aide #2 | CNA | Observed assisting resident with oral care and repositioning. |
| Nursing Home Administrator | NHA | Provided interviews and information on training and vaccination rates. |
| Infection Preventionist | IP | Provided training and monitoring of infection control practices. |
| Minimum Data Set Coordinator | MDSC | Assisted with infection data collection and surveillance. |
| Director of Nursing | DON | Participated in infection surveillance and monitoring. |
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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