Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
32 residents
Based on a April 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Centre Ave Health and Rehabilitation LLC.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians and family members of residents' changes in condition, failure to administer medications as ordered, and inadequate supervision to prevent accidents and falls.
Complaint Details
The complaint investigation revealed substantiated findings that the facility failed to notify physicians and family members of changes in condition, failed to administer medications as ordered, and failed to provide adequate supervision to prevent falls and injuries.
Findings
The facility failed to notify physicians and family members of changes in condition for three residents, failed to administer medications according to physician orders for two residents, and failed to provide adequate supervision to prevent accidents and falls for three residents. Multiple falls and injuries occurred without proper notification or intervention.
Deficiencies (3)
Failure to immediately inform the resident, the resident's doctor, and a family member of situations that affect the resident, including skin tear and falls for residents #33, #59, and #64.
Failure to ensure residents #18 and #16 were administered medications according to physician's orders, including multiple refusals and missed doses without provider notification.
Failure to ensure adequate supervision to prevent accidents and falls for residents #53, #16, and #33, resulting in multiple falls and injuries.
Report Facts
Residents in sample: 32
Residents affected by notification failure: 3
Residents affected by medication administration failure: 2
Residents affected by supervision failure: 3
Medication refusals: 27
Falls: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in relation to failure to notify physicians and family of resident falls and skin tear |
| WN | Wound Nurse | Acknowledged failure to notify family and physician of resident falls and skin tear |
| CSM #1 | Clinical Services Manager | Provided facility policies and interviewed regarding notification and fall prevention |
| CNC #1 | Clinical Nurse Consultant | Provided medication and treatment policy and interviewed about medication administration |
| CN #2 | Charge Nurse | Interviewed about medication administration and resident refusals |
| ADON | Assistant Director of Nursing | Interviewed about medication administration and notification procedures |
| NHA | Nursing Home Administrator | Interviewed about fall prevention policies and resident supervision |
| CNA #1 | Certified Nurse Assistant | Interviewed about purposeful rounding and resident supervision |
| CNA #2 | Certified Nurse Assistant | Interviewed about toileting program and resident care |
| CNA #3 | Certified Nurse Assistant | Interviewed about purposeful rounding and toileting program |
| AC #1 | Admission Coordinator | Interviewed about fall risk communication and admission procedures |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: Feb 9, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide necessary assistance with activities of daily living and pressure ulcer care for residents.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate assistance with eating and pressure ulcer care for Residents #16 and #18, resulting in minimal to actual harm.
Findings
The facility failed to provide adequate assistance with eating for Resident #16, resulting in a decline in activities of daily living. Additionally, the facility failed to provide timely and appropriate pressure ulcer care for Residents #16 and #18, including failure to implement pressure relieving interventions and inconsistent documentation of offloading boots use.
Deficiencies (2)
Failure to provide necessary assistance with eating for Resident #16, who required physical assistance and encouragement.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Residents #16 and #18, including delayed implementation of low air loss mattress and inconsistent offloading interventions.
Report Facts
Residents in sample: 28
Refusals of offloading boots: 6
Weight loss percentage: 4.7
Pressure ulcer stage: 2
Days delay for low air loss mattress: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #1 | Dietary Aide | Delivered meal tray to Resident #16 but did not provide physical assistance or encouragement to eat |
| CNA #1 | Certified Nurse Aide | Observed assisting Resident #16 with repositioning but did not physically assist with eating |
| WCN | Wound Care Nurse | Provided wound care for Resident #16 and reported on pressure ulcer status and interventions |
| DON | Director of Nursing | Provided facility policy and described assist to dine program and staff responsibilities |
| RD | Registered Dietitian | Provided nutritional assessments and orders for Resident #16 |
| DA #2 | Dietary Aide | Interviewed regarding assist to dine program and Resident #16's eating assistance |
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