Inspection Reports for
City Park Healthcare and Rehabilitation Center
1667 SAINT PAUL ST, DENVER, CO, 80206-1614
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Colorado average
Colorado average: 5.2 deficiencies/year
Deficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 1
Date: Dec 10, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to ostomy treatment and wound care for residents, specifically focusing on Resident #4's ostomy care.
Findings
The facility failed to provide appropriate ostomy care according to physician's orders for Resident #4, including inconsistent application of treatments, failure to follow infection control procedures, and inadequate documentation and education regarding ostomy care.
Deficiencies (1)
F 0684: The facility failed to provide appropriate ostomy care for Resident #4 according to physician's orders. Nurses did not consistently change ostomy appliances, failed to apply prescribed skin prep and nystatin powder, and did not follow proper hand hygiene and glove change protocols.
Report Facts
Residents reviewed for ostomy care: 4
Resident BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed performing ostomy care without following physician's orders or infection control procedures. |
| RN #2 | Registered Nurse | Interviewed regarding facility policy on checking physician's orders before treatments. |
| LPN #2 | Licensed Practical Nurse | Interviewed about resident self-administration of treatments and nursing responsibilities. |
| ADON | Assistant Director of Nursing | Interviewed about wound care supplies, use of designated scissors, and nursing responsibilities. |
| CNA #3 | Certified Nurse Aide | Interviewed about ostomy bag emptying practices and nursing responsibilities. |
| DON | Director of Nursing | Interviewed about nursing responsibilities, documentation, and follow-up on skin issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of physical abuse between two residents at the facility.
Complaint Details
The complaint investigation substantiated that Resident #2 physically abused Resident #1 by pushing her, resulting in a wrist fracture. Adult Protective Services substantiated the event but closed the case due to no evidence of staff abuse.
Findings
The facility failed to ensure Resident #1 was free from abuse when Resident #2 pushed Resident #1, causing a fall and a left wrist fracture. The investigation included staff interviews, resident care plan reviews, and documentation of behavioral histories.
Deficiencies (1)
F 0600: The facility failed to protect residents from abuse when Resident #2 pushed Resident #1, causing a fall and a left wrist fracture. The facility's investigation confirmed the incident and documented actual harm.
Report Facts
Residents Affected: 1
Date of incident: Sep 7, 2025
Date of survey completion: Oct 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Witnessed Resident #1 telling Resident #2 to shut up and Resident #2 pushing Resident #1. |
| Cook #1 | Cook | Witnessed the altercation between Resident #1 and Resident #2. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed the incident and described Resident #2's reaction to being told to shut up. |
| Social Services Director | Social Services Director | Conducted interviews and coordinated investigation following the incident. |
| Certified Nurse Aide #4 | Certified Nurse Aide | Provided information on Resident #1's behavior and abuse training. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding Resident #2's behavior and refusal of care. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented Resident #2's behavioral notes. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding verbal abuse of Resident #1 by a staff member at the facility.
Complaint Details
The complaint investigation found substantiated verbal abuse of Resident #1 by a dietary cook on 12/10/23. Resident #1 was afraid after the incident. The resident's legal power of attorney was not notified by the facility. The dietary cook was suspended and later terminated. Abuse training was delayed and provided over a month after the incident.
Findings
The facility failed to prevent verbal abuse of Resident #1 by a dietary cook who yelled profanity and threatened the resident. The dietary cook was terminated after the incident, and abuse training was provided to staff over a month later.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 from verbal abuse by a staff member who yelled and cursed at the resident. The dietary cook threatened to shove bread up the resident's 'expletive' during a kitchen incident on 12/10/23.
Report Facts
Residents sampled: 6
Residents affected: 1
Date of incident: Dec 10, 2023
Date of survey: Mar 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook | Staff member who verbally abused Resident #1 and was terminated | |
| Housekeeper | Witnessed the dietary cook yelling at Resident #1 | |
| Dietary Manager | Provided information about Resident #1's meal requirements and kitchen staff | |
| Assistant Dietary Manager | Heard the dietary cook yelling and took action to suspend him | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding Resident #1's bread requirements | |
| Certified Nurse Aide (CNA) #1 | Interviewed regarding Resident #1's bread requirements | |
| Nursing Home Administrator (NHA) | Interviewed about incident reporting and staff education | |
| Interim Nursing Home Administrator (INHA) | Provided information on staff training and termination of dietary cook |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 11, 2024
Visit Reason
The inspection was conducted due to complaints regarding unresolved grievances, extended call light wait times, missed medications, and dialysis care issues for several residents.
Complaint Details
The investigation was complaint-driven based on grievances from Residents #1, #2, and #3 regarding call light wait times, missed medications, and dialysis scheduling. The complaints were substantiated with findings of unresolved grievances, medication omissions, and dialysis delays.
Findings
The facility failed to provide prompt efforts to resolve grievances for three residents, ensure timely dialysis care for one resident, and prevent significant medication errors related to a kidney failure medication for one resident.
Deficiencies (3)
F 0585: The facility failed to address, resolve, document, and follow up on grievances for three residents related to missing medications, call light wait times, and timely dialysis transport.
F 0698: The facility failed to ensure Resident #1 was ready to leave timely for dialysis, resulting in frequent late arrivals and shortened dialysis sessions.
F 0760: The facility failed to ensure Resident #1 received all doses of prescribed kidney failure medication Velphoro, resulting in a significant medication error of omission.
Report Facts
Residents affected: 3
Dialysis sessions missed: 1.5
Phosphate level: 6
Phosphate level: 2.6
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of misappropriation of property and financial exploitation of residents by staff members.
Complaint Details
The investigation was complaint-driven, focusing on allegations of financial exploitation and theft involving residents #19, #44, #48, and #49. The complaints were substantiated with evidence including resident interviews, facility investigations, police involvement, and staff admissions.
Findings
The facility failed to prevent staff from exploiting money from four residents. Investigations revealed multiple incidents of staff borrowing or stealing money and fraudulent use of residents' financial information. The facility took actions including suspending staff, notifying police and the State Nursing Board, and providing locked boxes to residents.
Deficiencies (1)
F 0602: The facility failed to protect residents from misappropriation of property and financial exploitation by staff members involving four residents. Multiple staff members were implicated in borrowing money without repayment, theft, and fraudulent financial activities.
Report Facts
Amount of money borrowed by CNA #11: 8600
Check cashed by assailant: 700
Check attempted to cash: 2650
Fraudulent charges: 1195.51
Fraudulent charges: 369.44
Credit card charge: 400
Missing money: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #11 | Certified Nurse Aide | Borrowed approximately $8,600 from Resident #48 and resigned after investigation. |
| CNA #10 | Certified Nurse Aide | Confessed to forging a $2,650 check related to Resident #19's financial exploitation. |
| CNA #9 | Certified Nurse Aide | Suspected of stealing Resident #44's credit card and implicated in Resident #19's case. |
| Activities Director | Activities Director | Interviewed regarding resident education on financial protection. |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding staff training and resident education on financial exploitation prevention. |
Inspection Report
Routine
Deficiencies: 17
Date: Oct 12, 2023
Visit Reason
Routine state inspection survey of City Park Healthcare and Rehabilitation Center to assess compliance with regulatory requirements including medication self-administration, resident environment, abuse prevention, restraint use, PASRR compliance, activities, pressure injury care, pain management, medication storage, food safety, and infection control.
Findings
The facility had multiple deficiencies including failure to ensure proper medication self-administration assessment and orders, inadequate resident environment cleanliness and repair, failure to prevent resident-to-resident abuse, misappropriation of resident property by staff, improper use of physical restraints without physician orders, failure to incorporate PASRR recommendations and notify state mental health agency of significant changes, inadequate communication support for non-English speaking resident, failure to provide meaningful activities, inadequate pressure injury care and pain management, improper medication storage and disposal, unsanitary food service practices, and lapses in infection control including improper CPAP mask storage and hand hygiene during medication administration.
Deficiencies (17)
F554: Facility failed to assess and obtain physician orders for self-administration of medications for Resident #39 and failed to observe medication intake as required.
F584: Facility failed to maintain a clean, comfortable, and homelike environment for residents, including Resident #36 and #100, with issues of room cleanliness, odors, and repair.
F600: Facility failed to prevent resident-to-resident abuse between Residents #48 and #66, and failed to substantiate abuse appropriately.
F602: Facility failed to prevent misappropriation of property by staff from Residents #19, #44, #48, and #49, including large sums of money and credit card theft.
F604: Facility failed to ensure Resident #102 was free from physical restraints without physician orders and failed to assess and document use of lap belt restraint.
F644: Facility failed to incorporate PASRR level II recommendations into care planning and failed to provide timely services for Resident #83.
F646: Facility failed to notify the state mental health agency of significant changes in mental condition and psychiatric hospitalizations for Residents #33, #36, and #97.
F676: Facility failed to ensure Resident #12 was able to communicate in her preferred language and failed to provide communication aids such as a communication book.
F678: Facility failed to ensure medical orders for Resident #70's resuscitation wishes matched the MOST form, risking unwanted resuscitation.
F679: Facility failed to provide individualized meaningful activities for Resident #11 and failed to provide scheduled activities and invitations for Resident #83.
F686: Facility failed to provide appropriate pressure injury care for Resident #99 including repositioning, heel offloading, and nutritional supplements.
F697: Facility failed to implement and follow pain management protocols for Resident #99, including lack of pain scale use and inappropriate morphine administration.
F742: Facility failed to provide appropriate treatment and services including individualized non-pharmacological approaches for Residents #33 and #97 with mental disorders.
F744: Facility failed to provide consistent, person-centered dementia care and meaningful activity for Resident #99.
F761: Facility failed to properly discard expired medications, maintain locked medication storage rooms, and consistently monitor refrigerator temperatures.
F812: Facility failed to ensure proper hand hygiene and hair net use by staff in kitchen areas and failed to maintain clean refrigerators on units.
F880: Facility failed to maintain infection control including improper storage of CPAP masks, failure to perform hand hygiene during medication administration, and improper disposal of needles.
Report Facts
Expired medications: 4
Pressure injuries: 3
Morphine doses with zero pain scale: 5
Refrigerator temperature missing days: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration hand hygiene and unattended medication cart findings. |
| RN #2 | Registered Nurse | Named in medication storage temperature monitoring and hand hygiene observations. |
| LPN #2 | Licensed Practical Nurse | Named in improper sharps disposal observation. |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies in medication storage, infection control, and care planning. |
| AD | Activities Director | Named in interviews regarding activity programming deficiencies. |
| SSD | Social Services Director | Named in interviews regarding PASRR and behavioral care planning deficiencies. |
| NSD | Nutrition Service Director | Named in interviews regarding food service and kitchen hygiene. |
Inspection Report
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
The inspection was conducted to evaluate compliance with Medicare Advance Beneficiary Notice of Noncoverage (ABN) requirements related to residents discharged from Medicare Part A services but remaining in the facility.
Findings
The facility failed to provide advance beneficiary protection notification (ABN) for three residents reviewed who were discharged from Medicare Part A services but remained in the facility. The facility lacked an ABN policy and did not complete ABN forms for any of the residents discharged with benefits remaining.
Deficiencies (1)
F 0582: The facility failed to provide advance beneficiary notice (ABN) for three residents discharged from Medicare Part A services with benefits remaining but who remained in the facility. The facility did not have an ABN policy and did not complete ABN forms as required.
Report Facts
Residents reviewed: 9
Residents with ABN failure: 3
Residents discharged from Medicare A services: 13
Residents remaining in facility after Medicare A discharge: 11
Inspection Report
Routine
Deficiencies: 10
Date: Jul 14, 2022
Visit Reason
Routine inspection of City Park Healthcare and Rehabilitation Center to assess compliance with regulatory standards including medication administration, care planning, food safety, infection control, and resident care.
Findings
The facility had multiple deficiencies including failure to assess residents for medication self-administration, incomplete abuse investigations, failure to follow care plans and physician orders, medication errors, food allergy violations, poor kitchen sanitation, and inadequate infection control practices during wound care.
Deficiencies (10)
F 0554: The facility failed to ensure residents #99 and #100 were assessed for safe self-administration of medications as required by policy.
F 0610: The facility failed to thoroughly investigate an allegation of verbal abuse involving Resident #257, missing interviews with key staff.
F 0656: The facility failed to provide supplemental nutritional items as ordered for Resident #57, missing ice cream at meals.
F 0657: The facility failed to revise Resident #96's care plan to reflect the current physician order for oxygen administration.
F 0658: The facility failed to prevent Resident #57 from using straws despite orders prohibiting their use due to aspiration risk.
F 0695: The facility failed to administer oxygen at the prescribed flow rate for Resident #96, observed at 2.5 L/min instead of 1 L/min.
F 0759: The facility had a medication error rate of 6.25%, including incorrect dosing of furosemide and improper timing of levothyroxine administration.
F 0806: The facility failed to prevent Resident #40 from being served foods to which they had allergies and intolerances, including carrots.
F 0812: The facility failed to maintain proper food safety practices in the kitchen including undated and uncovered foods, improper food storage, dented cans, incomplete hair coverings, unclean food storage bins, personal drinks in food areas, and incomplete temperature logs.
F 0880: The facility failed to perform proper hand hygiene and aseptic technique during wound care for Resident #60, including failure to change gloves between dirty and clean tasks.
Report Facts
Medication error rate: 6.25
Medication dose: 80
Medication dose: 100
Medication dose: 88
Oxygen flow rate ordered: 1
Oxygen flow rate observed: 2.5
BIMS score: 9
BIMS score: 12
BIMS score: 13
BIMS score: 15
Medication administration opportunities: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Administered incorrect dose of furosemide and levothyroxine medication errors. |
| LPN #4 | Licensed Practical Nurse | Observed failing to change gloves during wound care for Resident #60. |
| RN #6 | Registered Nurse | Observed wound care and noted infection control issues. |
| Director of Nursing | Director of Nursing | Provided multiple interviews confirming expectations for care plans, medication administration, abuse investigations, kitchen sanitation, and infection control. |
| Administrator | Administrator | Provided multiple interviews confirming expectations for facility compliance and staff accountability. |
| FNSD | Food and Nutrition Services Director | Interviewed regarding kitchen sanitation and food safety deficiencies. |
| RD | Registered Dietitian | Interviewed regarding nutritional care and kitchen sanitation. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding no straw orders and medication administration expectations. |
| CNA #8 | Certified Nursing Assistant | Interviewed regarding food allergy and abuse investigation deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Apr 15, 2021
Visit Reason
The inspection was the annual recertification survey and complaint investigation of City Park Healthcare and Rehabilitation Center to assess compliance with state and federal regulations.
Complaint Details
The inspection included complaint investigations related to abuse allegations, medication errors, and resident safety concerns. Several abuse allegations were found not fully investigated or substantiated due to incomplete investigations. The facility failed to ensure resident safety related to smoking hazards and medication administration. The complaint investigations contributed to the identification of multiple deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate investigation of abuse allegations, inaccurate minimum data set assessments, failure to provide appropriate care for activities of daily living, inadequate activities programming, medication administration errors, failure to ensure safe smoking practices leading to resident burns, improper medication storage, food served at unsafe temperatures, failure to provide adaptive eating utensils, and lack of a comprehensive facility assessment to address resident needs and safety.
Deficiencies (16)
F550: The facility failed to treat residents with dignity and respect, including staff making inappropriate comments about residents and failure to meet individual resident needs.
F600: The facility failed to ensure residents were free from physical, verbal, and mental abuse and failed to thoroughly investigate abuse allegations.
F636: The facility failed to ensure minimum data set (MDS) assessments were completed accurately for multiple residents.
F676: The facility failed to provide necessary care and services to maintain or improve residents' abilities in activities of daily living, including failure to provide assistance and encouragement with eating.
F679: The facility failed to provide an ongoing resident-centered activities program to meet residents' needs and interests, including failure to provide meaningful activities and one-to-one programming.
F684: The facility failed to provide treatment and care in accordance with professional standards and comprehensive care plans, including medication errors, failure to monitor for bleeding, failure to provide foot rests, and failure to identify and treat skin wounds.
F689: The facility failed to ensure resident safety with accident hazards, including failure to provide safe smoking supervision and interventions, and failure to investigate equipment malfunction and assess involved resident.
F695: The facility failed to provide appropriate respiratory care consistent with physician orders and professional standards, including failure to obtain oxygen orders, administer oxygen as ordered, label oxygen tubing, and maintain accurate care plans.
F744: The facility failed to provide appropriate dementia care services and therapeutic programming, including failure to provide person-centered care, behavior monitoring, and non-pharmacological interventions.
F758: The facility failed to ensure residents did not receive unnecessary psychotropic medications, including failure to provide rationale for antipsychotic use and to track sleep and behavior monitoring.
F761: The facility failed to ensure medications were labeled, expired medications removed, medications locked, medication refrigerators maintained at proper temperatures, and medications stored properly.
F804: The facility failed to ensure food was palatable and served at safe temperatures, including failure to reheat food to required temperatures and improper food handling.
F810: The facility failed to provide adaptive eating utensils for residents who required them, including failure to provide weighted utensils and spouted cups as ordered.
F812: The facility failed to ensure proper reheating and holding temperatures of food were maintained to prevent foodborne illness.
F838: The facility failed to conduct a thorough facility-wide assessment to determine necessary resources to care for residents competently during day-to-day operations and emergencies, including failure to address resident smoking safety.
F880: The facility failed to maintain an infection prevention and control program to provide a safe, sanitary environment and prevent communicable diseases, including failure to properly empty catheter bags, disinfect shared activity equipment, and label personal hygiene items.
Report Facts
Residents affected by abuse: 3
Residents with cigarette burns: 1
Expired medication: 1
Temperature of medication refrigerator: 52
Residents smoking: 15
Resident incontinent episodes: 35
Resident catheter bag not changed timely: 1
Residents with unlabelled personal items: 2
Residents not offered condiments: 3
Residents not offered snacks: 2
Residents with unheated or cold food: 8
Residents without adaptive utensils: 3
Residents with oxygen tubing unlabeled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #3 | Dietary Aide | Made inappropriate comment about Resident #6. |
| NHA | Nursing Home Administrator | Interviewed multiple times regarding abuse investigations, facility assessment, and QAPI. |
| DON | Director of Nursing | Interviewed regarding abuse investigations, medication administration, catheter care, and facility assessment. |
| ADON #1 | Assistant Director of Nursing | Interviewed regarding skin assessments and restorative nursing. |
| ADON #2 | Assistant Director of Nursing/Restorative Nurse | Interviewed regarding restorative nursing and contracture care. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and oxygen tubing. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration and oxygen tubing. |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding medication storage and labeling. |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication storage and refrigerator temperature. |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding oxygen administration and tubing labeling. |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding medication storage and refrigerator temperature. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding toileting assistance and restorative care. |
| CNA #7 | Certified Nurse Aide | Interviewed regarding toileting assistance and resident engagement. |
| CNA #12 | Certified Nurse Aide | Observed serving food at unsafe temperature. |
| CNA #13 | Certified Nurse Aide | Interviewed regarding toileting assistance and restorative care. |
| CNA #14 | Certified Nurse Aide | Observed medication storage room access and medication labeling issues. |
| CNA #15 | Certified Nurse Aide | Interviewed regarding labeling of personal hygiene items in shared rooms. |
| AD | Activity Director | Interviewed regarding activities programming and infection control during activities. |
| SSD | Social Service Director | Interviewed regarding abuse investigations and resident glasses follow-up. |
| SW #2 | Social Worker | Interviewed regarding psychotropic medication monitoring and resident glasses follow-up. |
| DOT | Director of Therapy | Interviewed regarding restorative nursing programs and contracture care. |
| DM | Dietary Manager | Interviewed regarding food temperature and quality. |
| RD | Registered Dietitian | Interviewed regarding food quality and activities. |
| IP | Infection Preventionist | Interviewed regarding infection control during activities. |
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