Inspection Reports for
Crestmoor Care Center
895 S MONACO PKWY, DENVER, CO, 80224-1501
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 2, 2025
Visit Reason
The inspection was conducted due to multiple incidents of resident-to-resident abuse involving physical and verbal altercations between residents, including allegations of physical abuse by Resident #6 towards Resident #12 and by Resident #4 towards Residents #5, #9, and #15.
Complaint Details
The investigation was complaint-driven, focusing on allegations of abuse between residents. The facility investigation did not substantiate some incidents but confirmed multiple episodes of physical and verbal abuse. Resident #6 was identified as an aggressor with delusional thinking and cognitive impairment. Resident #4 was intoxicated during his aggressive behavior. The facility lacked sufficient interventions to prevent recurrence.
Findings
The facility failed to protect several residents from physical and verbal abuse by other residents, despite having policies and interventions in place. Multiple incidents of abuse were documented, including physical altercations causing injury and distress. Staff interventions and monitoring were insufficient to prevent repeated incidents. The facility also lacked documentation of one-to-one observations for an intoxicated resident who was aggressive.
Deficiencies (2)
Failure to prevent multiple abuse altercations between Resident #6 and Resident #12.
Failure to protect Resident #5, Resident #9 and Resident #15 from physical abuse by Resident #4.
Report Facts
Residents affected: 4
BIMS score: 3
BIMS score: 13
BIMS score: 13
BIMS score: 15
Tylenol dosage: 650
Training compliance: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Interviewed as a witness to multiple incidents involving Resident #6 and Resident #12, reported incidents to DON, NHA, and police. |
| LPN #2 | Licensed Practical Nurse | Witnessed and intervened in altercation between Resident #6 and Resident #12, reported incident to SSD and NHA. |
| CNA #4 | Certified Nurse Aide | Witnessed altercation between Resident #6 and Resident #12, assisted in separating residents. |
| Director of Nursing | Director of Nursing | Interviewed regarding management of conflicts between Resident #6 and Resident #12. |
| Social Services Director | Social Services Director | Interviewed residents and provided insight on Resident #6's behavior and medication adjustments. |
| NHA | Nursing Home Administrator | Interviewed regarding facility policies, staff training, and resident safety related to abuse incidents. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 17, 2025
Visit Reason
The inspection was conducted to investigate allegations of abuse made by Resident #1, who claimed that staff and other residents were trying to harm her.
Complaint Details
The complaint investigation was triggered by Resident #1's allegations that her granddaughter hired a CNA to try to kill her. The investigation revealed delays and failure to promptly start the investigation. Resident #1 had severe cognitive impairments and a history of delusions. The complaint was substantiated with findings of inadequate investigation.
Findings
The facility failed to complete a thorough and timely investigation into the abuse allegations made by Resident #1. Despite multiple interviews with staff, residents, and family members, the investigation was delayed and incomplete, with the social services director reporting that the nursing home administrator delayed initiating the investigation.
Deficiencies (1)
Failed to investigate allegations of abuse for one resident, including delays and incomplete investigation.
Report Facts
Residents reviewed for abuse: 5
Residents affected: 1
BIMS score: 0
15-minute checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse taking care of Resident #1 on the evening of 4/14/25, involved in reporting and monitoring after the incident. |
| RN #2 | Registered Nurse | Interviewed Resident #1 and reported history of accusations by Resident #1. |
| NHA | Nursing Home Administrator | Received abuse policy and was involved in decisions delaying investigation. |
| SSD | Social Services Director | Determined Resident #1 was fearful of staff, reported delays in investigation. |
| DON | Director of Nursing | Interviewed regarding notification procedures and investigation guidance. |
| RCR #1 | Regional Clinical Resource | Initiated investigation after identifying nursing progress note. |
| RCR #2 | Regional Clinical Resource | Interviewed regarding investigation and findings. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 6, 2025
Visit Reason
The inspection was conducted to investigate allegations of abuse involving residents and to assess compliance with care standards related to activities of daily living and infection control.
Complaint Details
The complaint investigation was triggered by allegations of verbal and physical abuse between residents, failure to provide necessary assistance with activities of daily living, and inadequate infection control practices.
Findings
The facility failed to protect residents from verbal and physical abuse, failed to provide necessary assistance with activities of daily living including eating, repositioning, bathing, and oral care, and failed to maintain an effective infection prevention and control program including housekeeping practices, enhanced barrier precautions, catheter and tracheostomy care, and cleaning of equipment between residents.
Deficiencies (9)
Failed to protect Resident #77 from verbal abuse by Resident #23 and Resident #69 from physical abuse by Resident #235.
Failed to provide appropriate repositioning for eating and eating supervision for Resident #80.
Failed to provide timely eating assistance for Resident #1.
Failed to provide timely repositioning, bathing and oral care for Resident #53.
Failed to ensure housekeeping staff followed proper cleaning techniques and hand hygiene.
Failed to ensure enhanced barrier precautions were in place for residents with wounds and indwelling devices.
Failed to follow infection control procedures for catheter care, including improper wiping technique and lack of gown use.
Failed to follow infection control procedures for tracheostomy suctioning, including improper hand hygiene and contamination of sterile equipment.
Failed to clean vital signs equipment between residents.
Report Facts
Residents reviewed for abuse: 47
Residents reviewed for ADLs: 10
Bath frequency: 1
Observation duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA #1 | Restorative Nurse Aide | Observed and interviewed regarding verbal abuse incident between Resident #23 and Resident #77. |
| NHA | Nursing Home Administrator | Provided facility incident reports and interviews regarding abuse incidents and infection control. |
| RN #1 | Registered Nurse | Interviewed regarding resident behaviors, eating assistance, and infection control practices. |
| CNA #5 | Certified Nurse Aide | Interviewed regarding resident behaviors and catheter care. |
| CNA #6 | Certified Nurse Aide | Interviewed regarding resident behaviors and enhanced barrier precautions. |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding catheter care and PPE use. |
| RN #2 | Registered Nurse | Observed providing tube feeding care and tracheostomy suctioning; interviewed about PPE use. |
| HK #1 | Housekeeper | Observed performing cleaning with multiple infection control deficiencies. |
| HK #2 | Housekeeper | Observed performing cleaning with multiple infection control deficiencies. |
| ESD | Environmental Services Director | Interviewed regarding housekeeping policies and practices. |
| CC | Clinical Consultant | Provided policies and interviewed regarding infection control and abuse investigations. |
Inspection Report
Routine
Deficiencies: 15
Date: Feb 6, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility standards, including resident care, safety, infection control, and environmental conditions.
Findings
The facility was found deficient in multiple areas including resident dignity and care, grievance resolution, abuse prevention, activities of daily living assistance, pressure ulcer care, accident hazard prevention, catheter care, medication storage and labeling, food safety and sanitation, infection control practices, and equipment cleaning protocols.
Deficiencies (15)
Facility staff failed to treat residents with dignity, including inappropriate comments about residents' rooms and improper handling of residents.
Facility failed to provide prompt resolution to resident grievances.
Facility failed to protect residents from verbal and physical abuse by other residents.
Facility failed to provide necessary assistance with activities of daily living including eating, repositioning, bathing, and oral care.
Facility failed to provide appropriate pressure ulcer care and prevention interventions in a timely and consistent manner.
Facility failed to ensure an environment free from accident hazards and provide adequate supervision to prevent accidents, including elopement prevention and fall precautions.
Facility failed to ensure appropriate care and documentation for residents with indwelling urinary catheters, including lack of physician orders and care plans.
Facility failed to ensure medications and biologicals were properly stored and labeled, including expired medications and unlabeled injectable medications.
Facility failed to ensure food was stored, prepared, and served under sanitary conditions, including improper refrigeration temperatures and cross-contamination during food handling.
Facility failed to implement policy regarding use and storage of foods brought by visitors, including improper temperature monitoring and storage in residents' personal refrigerators.
Housekeeping staff failed to follow proper cleaning and disinfecting techniques, including inadequate hand hygiene, improper cleaning of high-touch surfaces, and failure to disinfect equipment between rooms.
Facility failed to maintain enhanced barrier precautions for residents with wounds and indwelling devices, including failure to wear gowns and gloves as required.
Facility failed to follow infection control procedures for catheter care, including improper PPE use and cleaning techniques.
Facility failed to follow infection control procedures for tracheostomy care, including improper aseptic technique and equipment handling.
Facility failed to clean vital signs equipment between residents, increasing risk of cross-contamination.
Report Facts
Behavior monitoring: 7
Pressure ulcer measurements: 2.2
Pressure ulcer measurements: 2.1
Pressure ulcer measurements: 0.7
Temperature: 56
Temperature: 58
Temperature: 42
Temperature: 42
Temperature: 44
Temperature: 42
Urine output: 450
Urine output: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK #1 | Housekeeper | Observed failing to perform proper cleaning and disinfection techniques in resident rooms. |
| HK #2 | Housekeeper | Observed failing to perform proper cleaning and disinfection techniques in resident rooms. |
| RN #1 | Registered Nurse | Observed providing care and interviewed regarding resident care and infection control. |
| RN #2 | Registered Nurse | Observed providing tracheostomy care without proper PPE. |
| LPN #1 | Licensed Practical Nurse | Observed providing catheter care without proper PPE and interviewed about catheter care. |
| CNA #5 | Certified Nurse Aide | Observed and interviewed regarding catheter care and infection control practices. |
| CNA #7 | Certified Nurse Aide | Observed assisting resident while smoking without enforcing use of adaptive equipment or supervision. |
| DON | Director of Nursing | Interviewed regarding multiple care and infection control deficiencies. |
| WCP | Wound Care Physician | Interviewed regarding wound care deficiencies. |
| DM | Dietary Manager | Interviewed regarding food safety and nourishment refrigerator temperature monitoring. |
| CC | Clinical Consultant | Interviewed regarding infection control and housekeeping practices. |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to assess compliance with medication labeling and storage requirements, and to evaluate the maintenance and testing of glucometers used for resident blood glucose monitoring.
Findings
The facility failed to ensure insulin pens were properly labeled with resident names and open dates on multiple medication carts, and failed to perform regular control solution tests on four of 15 glucometers used for blood glucose monitoring. Interviews revealed issues with labeling practices and glucometer testing documentation.
Deficiencies (2)
Failure to ensure insulin pens were labeled with resident's name and open dates on four medication carts.
Failure to perform regular control solution tests for four of 15 glucometers used for monitoring resident blood glucose.
Report Facts
Insulin pens unlabeled: 6
Glucometers missing control solution tests: 4
Glucometers per station: 3
Glucometers per station: 6
Glucometers per station: 3
Glucometers per station: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed medication cart and insulin pen labeling issues; interviewed about insulin pen open dates. |
| RN #1 | Registered Nurse | Reviewed medication cart with unlabeled insulin pens and observed medication administration. |
| LPN #2 | Licensed Practical Nurse | Reviewed medication cart with insulin pens labeled only with first names and no open dates; interviewed about glucometer control solution tests. |
| RN #2 | Registered Nurse | Reviewed medication cart with unlabeled insulin pens. |
| Corporate Nurse Consultant | Interviewed about insulin pen labeling and plan to work with pharmacist. | |
| Director of Nursing | Director of Nursing | Interviewed about importance of insulin pen dating. |
| Regional Quality Mentor | Provided facility policies and interviewed about insulin pen labeling and glucometer testing. | |
| Pharmacist | Interviewed about insulin pen labeling restrictions and solutions. |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident environment, bed hold notices during hospital transfers, and food safety standards in the facility.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean, comfortable, and homelike environment with issues such as cluttered and unsanitary resident rooms, failure to provide timely written bed hold notices to residents transferred to hospitals, and failure to maintain proper refrigerator temperatures for resident food storage.
Deficiencies (3)
Facility failed to provide a clean, comfortable, homelike environment; resident rooms and hallways were cluttered, unsanitary, with urine odors and stained linens.
Facility failed to provide written bed hold notices to residents #121 and #122 and their representatives at the time of hospital transfer, violating bed hold policy.
Facility failed to maintain proper refrigerator temperatures in resident snack refrigerators, with temperatures consistently above 41°F and no corrective actions documented.
Report Facts
Temperature readings: 46
Temperature readings: 44
Residents reviewed: 33
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Housekeeping Supervisor (HSKS) | Interviewed regarding cleaning deficiencies and housekeeping staffing |
| Nursing Home Administrator | NHA | Provided facility policies, interviewed regarding deficiencies and bed hold notices |
| Registered Nurse #1 | RN | Interviewed regarding refrigerator temperature monitoring |
| Social Services Director | SSD | Interviewed regarding discharge planning and bed hold notice responsibilities |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, environment, and food storage at Crestmoor Care Center.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of significant changes in condition, failure to maintain a clean and homelike environment, failure to provide bed hold notices upon hospital transfers, failure to ensure RN assessment after resident falls, failure to ensure resident safety during showering, failure to obtain physician orders for oxygen therapy, improper storage and disposal of expired medications, and failure to maintain proper refrigerator temperatures for resident food.
Deficiencies (8)
Failure to ensure immediate notification to the resident's representative of a significant change in the resident's condition.
Failure to provide a clean, comfortable, homelike environment including clean linens and odor-free rooms.
Failure to provide written bed hold notices to residents and representatives upon hospital transfer.
Failure to ensure Resident #64 was assessed by a registered nurse after a fall.
Failure to ensure Resident #25 had access to call light during showering and timely staff response when resident was stuck and coughing in shower room.
Failure to acquire a physician's order before administering oxygen to Resident #46.
Failure to dispose of expired Cephalexin and Levemir insulin pen beyond manufacturer recommended use.
Failure to maintain proper refrigerator temperatures for resident snack refrigerators, with temperatures consistently above 41 degrees F.
Report Facts
Residents reviewed: 35
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Expired medication days: 50
Refrigerator temperature: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Documented fall of Resident #64 and assisted resident without RN assessment |
| RN #1 | Registered Nurse | Assisted Resident #25 out of shower room and assessed oxygen saturation |
| NHA | Nursing Home Administrator | Provided facility policies and interviewed regarding deficiencies and corrective actions |
| DON | Director of Nursing | Interviewed regarding nursing practices, oxygen therapy orders, and staff education |
| CNA #1 | Certified Nursing Assistant with medication administration authority | Observed with expired Levemir insulin pen |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, PASARR screening, accommodation of resident needs, and medication storage in the facility.
Findings
The facility was found deficient in accommodating a resident's physical environment for safe transfers, completing required PASARR screening, administering medications correctly including via PEG tube, maintaining medication error rates below 5%, and ensuring medication and treatment carts were locked when unattended.
Deficiencies (5)
Failed to accommodate and individualize the physical environment of Resident #59's bathroom to allow safe wheelchair transfer to the commode.
Failed to complete a Level 1 PASARR screening for Resident #28 prior to admission.
Failed to provide appropriate treatment and services to prevent complications from enteral feedings for Resident #53 by not administering medications via gravity as required.
Failed to ensure medication error rate was less than 5%, with a 14.28% error rate observed for Residents #53 and #54 during medication administration.
Failed to ensure drugs and biologicals were stored in locked carts when unattended; observed unlocked medication cart and treatment carts with faulty locks.
Report Facts
Medication error rate: 14.28
Medication administration opportunities: 28
Medication errors observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Completed incident report for Resident #59 fall on 03/24/2022 and provided interview regarding fall and resident transfers. |
| RN #5 | Registered Nurse | Observed administering medications via PEG tube incorrectly and admitted to medication error. |
| LPN #4 | Licensed Practical Nurse | Prepared medications for Resident #54 and confused Lantus with Basaglar insulin. |
| LPN #3 | Licensed Practical Nurse | Observed leaving treatment cart unlocked and unaware of faulty lock. |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding Resident #59's bathroom use and transfers. |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding Resident #59's restroom use and call light usage. |
| ADON | Assistant Director of Nursing | Provided multiple interviews regarding facility policies, medication administration, and resident care. |
| RM | Rehabilitation Manager | Interviewed regarding Resident #59's fall risk and transfer assessments. |
| ADM | Administrator | Interviewed regarding facility policies, medication administration, and resident care. |
| MDS #1 | MDS Consultant | Interviewed regarding PASARR screening and resident clinical documentation. |
| NP #1 | Nurse Practitioner | Observed interacting near unlocked medication cart. |
| LP #1 | Licensed Pharmacist | Interviewed regarding insulin substitution and medication interchangeability. |
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