Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to investigate a deficiency related to the facility's failure to provide food accommodating resident allergies, intolerances, and preferences, specifically after a resident experienced an anaphylactic reaction due to being served fish despite a known allergy.
Findings
The facility failed to prevent Resident #1 from being served fish, which caused an anaphylactic shock requiring hospitalization. The investigation revealed staff did not check diet orders properly, resulting in disciplinary actions and terminations. The facility implemented immediate staff education, allergy audits, new signage, and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure each resident receives food that accommodates allergies, intolerances, and preferences, resulting in an allergic reaction requiring hospitalization.
Report Facts
Residents reviewed: 5
Residents affected: 1
Date of incident: Sep 24, 2025
Date of survey completion: Dec 9, 2025
Date of staff education: Sep 24, 2025
Date of allergy audit: Sep 29, 2029
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided facility investigation and education, involved in disciplinary actions |
| Director of Nursing | DON | Provided education, managed emergency response, interviewed during investigation |
| Certified Nurse Aide #1 | CNA | Admitted failure to check diet order ticket prior to serving resident; terminated |
| Cook #1 | Cook | Admitted failure to check diet ticket; had prior written warning; terminated |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding resident notification of changes in condition, abuse prevention, safe discharge and transfer procedures, and provision of mental health services.
Findings
The facility failed to notify representatives of significant resident condition changes for two residents, failed to protect one resident from verbal and physical abuse by another resident, failed to allow a resident to return after hospital discharge with proper documentation, and failed to provide mental health counseling services to a resident with behavioral symptoms.
Deficiencies (5)
Failed to notify Resident #2's representative of cardiology appointments and medication changes.
Failed to notify Resident #8's representative timely about pain, mobility issues, and hospital transfer.
Failed to protect Resident #4 from verbal and physical abuse by Resident #5.
Failed to allow Resident #1 to return to the facility after hospital discharge and failed to provide required discharge documentation.
Failed to provide mental health counseling services for Resident #1 despite behavioral symptoms and care plan recommendations.
Report Facts
Staff trained: 15
Residents reviewed: 8
Behavioral symptoms BIMS score: 12
Behavioral symptoms BIMS score: 4
Behavioral symptoms BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA | Nursing Home Administrator | Provided interviews regarding notification failures, abuse investigations, discharge procedures, and mental health service gaps. |
| DON | Director of Nursing | Interviewed about notification policies and abuse prevention measures. |
| RN #1 | Registered Nurse | Interviewed regarding Resident #5 care and behavior observations. |
| CNA #1 | Certified Nurse Aide | Interviewed about resident redirection and prevention of altercations. |
| CNA #2 | Certified Nurse Aide | Interviewed about resident redirection and prevention of altercations. |
| NM | Nurse Manager | Interviewed about Resident #1's behavior and EMS involvement. |
| SSD | Social Services Director | Interviewed about Resident #1's mental health services and family visits. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
The inspection was conducted due to complaints and grievances filed by residents regarding long wait times for staff response to call lights and delayed care.
Complaint Details
The complaint investigation was substantiated with findings that residents experienced long waits for call light responses and delayed care, including being left in soiled bedding for extended periods. Grievances submitted by residents were not properly handled or followed up on by staff and administration.
Findings
The facility failed to ensure prompt action was taken upon the filing of grievances related to long call light response times and delayed care. Multiple residents reported wait times ranging from 30 minutes to over an hour for assistance, and grievances were not properly tracked or addressed in a timely manner.
Deficiencies (1)
Failed to follow up with residents' concerns regarding call light times and delayed care.
Report Facts
Call light response times: 46
Call light response times: 40
Number of grievances: 3
Staff education attendance: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA | Nursing Home Administrator | Interviewed multiple times regarding grievance handling and call light response times |
| SSD | Social Service Director | Interviewed regarding grievance process and handling |
| DON | Director of Nursing | Interviewed regarding call light response times and resident grievances |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to assist Resident #1 with turning in bed upon request and failure to ensure Resident #8 received a full course of prescribed antibiotics.
Complaint Details
The complaint investigation found substantiated issues related to Resident #1's dignity and care preferences not being honored and Resident #8 missing seven doses of prescribed antibiotics due to pharmacy refill and communication failures.
Findings
The facility failed to ensure Resident #1 was assisted to turn in bed when requested, impacting dignity and care, and failed to ensure Resident #8 received all prescribed doses of antibiotics, resulting in a significant medication error.
Deficiencies (2)
Failed to assist Resident #1, dependent on staff for all care, to turn in bed when requested.
Failed to ensure Resident #8 received full three-week course of antibiotics as prescribed.
Report Facts
Doses of Augmentin prescribed: 32
Doses of Augmentin received: 26
Missed doses: 7
BIMS score Resident #1: 15
BIMS score Resident #8: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #1's care and Resident #8's medication administration |
| Director of Nursing | DON | Provided facility policy, interviewed about Resident #1 and Resident #8 care issues, and follow-up actions |
| Medical Director | MD | Interviewed regarding Resident #8's antibiotic treatment and medication errors |
| Pharmacist | PH | Interviewed about medication refill issues related to Resident #8 |
Inspection Report
Deficiencies: 19
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements, including resident care, grievance handling, medication management, infection control, and other quality of care and safety standards.
Findings
The facility had multiple deficiencies including failure to promptly address resident grievances about call light response times, inadequate management of personal funds, failure to provide timely Medicare non-coverage notices, incomplete investigations of abuse allegations, failure to coordinate PASRR assessments, incomplete discharge summaries, failure to provide restorative therapy services, incomplete staff performance reviews and training, failure to post nurse staffing information, improper medication storage, failure to ensure proper diet textures, inadequate infection preventionist staffing, use of non-medical grade blood pressure cuffs, failure to maintain sanitary food preparation and storage, incomplete hospice care documentation, and ineffective quality assurance program implementation.
Deficiencies (19)
Failure to promptly address resident grievances concerning call light response times.
Failure to have personal funds withdrawal sheets signed to ensure resident permission.
Failure to provide timely Notice of Medicare Provider Non-Coverage (NOMNC) to resident.
Failure to investigate an allegation of abuse where a staff member threatened a resident.
Failure to coordinate PASRR Level II evaluations for five residents as required.
Failure to ensure a complete discharge summary including functional and cognitive status.
Failure to assist resident in obtaining new eyeglasses after prescription was updated.
Failure to provide restorative therapy services to maintain resident's physical function.
Failure to complete annual performance reviews and provide in-service education for CNAs.
Failure to post nurse staffing information daily and maintain staffing data for 18 months.
Failure to limit PRN psychotropic medications to 14 days or document rationale for longer use.
Failure to ensure all medications and biologicals were stored securely and maintain refrigerator temperature logs.
Failure to serve food prepared in a form designed to meet individual resident needs per physician orders.
Failure to prepare, store, distribute and serve food in a sanitary manner including hand hygiene and food labeling.
Failure to ensure hospice agency notes were accessible to facility staff to coordinate care.
Failure to implement an effective quality assurance and performance improvement program.
Failure to designate a qualified infection preventionist with adequate time to manage the program.
Failure to use blood pressure cuffs rated for medical use to obtain accurate resident blood pressures.
Failure to provide required annual training to staff on abuse, dementia management, and resident abuse prevention.
Report Facts
Residents interviewed for call light concerns: 6
Call light response times: 53
Personal funds withdrawals without authorization: 3
Days missing refrigerator temperature logs: 14
CNA annual training hours: 6.75
CNA annual training hours: 4
CNA annual training hours: 4.5
CNA annual training hours: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #7 | Interviewed about call light response delays and grievances. | |
| Resident #54 | Interviewed about lack of restorative therapy services and physical decline. | |
| Business Office Manager | Business Office Manager | Interviewed about personal funds withdrawal authorization and receipts. |
| Social Service Director | Social Service Director | Interviewed about grievance process, PASRR coordination, and hospice care documentation. |
| Director of Nursing | Director of Nursing | Interviewed about call light response education, restorative therapy, infection prevention, and staff training. |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about grievance handling, staff training, infection control, and quality assurance. |
| Regional Operations Manager | Regional Operations Manager | Interviewed about QAPI program, call light concerns, and infection preventionist staffing. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about restorative therapy knowledge and lack of performance review. |
| Certified Nurse Aide #5 | Certified Nurse Aide | Interviewed about lack of performance review and training. |
| Certified Nurse Aide #4 | Certified Nurse Aide | Interviewed about lack of performance review and training. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Record review showed no annual performance review. |
| Dietary Director | Dietary Director | Interviewed about food preparation, diet texture compliance, and food labeling. |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Interviewed about medication refrigerator temperature logging and blood pressure cuff use. |
| Registered Nurse #1 | Registered Nurse | Interviewed about blood pressure cuff use and medication cart locking. |
| Pharmacist | Pharmacist | Interviewed about PRN psychotropic medication order durations. |
| Corporate Consultant | Corporate Consultant | Interviewed about PRN medication orders and hospice communication. |
| Medical Records Director | Medical Records Director | Interviewed about receipt of hospice notes. |
| Physical Therapist | Physical Therapist | Interviewed about restorative therapy services. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about restorative therapy services and recommendations. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Training record reviewed for annual education. |
| Activities Assistant | Activities Assistant | Training record reviewed for abuse and dementia training. |
| Cook | Cook | Training record reviewed for abuse and dementia training. |
| Housekeeper #1 | Housekeeper | Training record reviewed for abuse and dementia training. |
| Dietary Aide #2 | Dietary Aide | Training record reviewed for dementia training. |
| Maintenance Assistant | Maintenance Assistant | Training record reviewed for dementia training. |
Inspection Report
Routine
Deficiencies: 8
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, safety, nutrition, infection control, and water management.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of changes in condition, failure to provide restorative therapy services, inadequate fall prevention and supervision, failure to maintain adequate nutrition and food quality, lapses in infection control practices including housekeeping and PPE use, failure to offer hand hygiene before meals, failure to change soiled linens after wound care, and lack of an effective water management program.
Deficiencies (8)
Failure to notify resident representative of a change of condition after an unwitnessed fall for Resident #173.
Failure to provide restorative therapy services to Resident #54 with limited range of motion.
Failure to provide adequate supervision and assistance to prevent falls and failure to assess, implement and monitor interventions consistent with resident needs for Resident #173.
Failure to provide enough food/fluids to maintain Resident #54's health, including failure to assess and intervene after severe weight loss.
Failure to ensure food was served palatable, attractive, and at appropriate temperature.
Failure to maintain an infection control program including improper glove use and hand hygiene by housekeeping, improper disinfectant use, failure to don PPE for residents on enhanced barrier precautions, failure to provide clean linens after wound care, failure to offer hand hygiene before meals, and lack of an effective water management plan.
Failure to offer hand hygiene to residents before meals.
Failure to change soiled bedding after wound dressing change for Resident #166.
Report Facts
Residents reviewed: 45
Weight loss: 26
Weight loss: 12.2
Staff educated: 36
Temperature: 130
Temperature: 103
Temperature: 54.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding fall notification, restorative therapy, and infection control deficiencies |
| Certified Nurse Aide #2 | Certified Nurse Aide | Reported bruise on Resident #173 and interviewed about restorative therapy and infection control |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed regarding restorative therapy and weight monitoring |
| Physical Therapist | Physical Therapist | Interviewed regarding restorative therapy services |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding restorative therapy services |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding restorative therapy, smoking policy, food quality, infection control, and water management |
| Regional Operations Manager | Regional Operations Manager | Interviewed regarding restorative therapy and water management |
| Housekeeper #2 | Housekeeper | Observed and interviewed regarding cleaning practices and disinfectant use |
| Housekeeper #3 | Housekeeper | Observed and interviewed regarding cleaning practices and disinfectant use |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and interviewed regarding PPE use and wound care |
| Certified Nurse Aide #7 | Certified Nurse Aide | Interviewed regarding hand hygiene before meals |
| Director of Maintenance | Director of Maintenance | Interviewed regarding water management program |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent elopement of a resident identified as at risk for wandering.
Complaint Details
The complaint investigation was substantiated as the facility failed to prevent elopement of Resident #2, who was at risk for wandering. The resident eloped on 7/15/23, was missing for over seven hours, and was found with minor injuries. Staff interviews revealed lack of communication and inadequate monitoring.
Findings
The facility failed to identify goals and interventions on the baseline care plan to ensure Resident #2's safety related to elopement, failed to provide thorough shift reports about the resident's wandering, and failed to prevent Resident #2 from eloping. The resident was found after being missing for over seven hours with minor injuries. The facility lacked proper monitoring and use of wander guards despite documented risk.
Deficiencies (3)
Failed to identify goals and interventions on the baseline care plan to ensure Resident #2's health and safety related to elopement
Failed to ensure a thorough shift report was provided to the oncoming nurse during change of shift to inform of Resident #2's wandering activities
Failed to ensure Resident #2 did not elope from the facility
Report Facts
Wandering Risk Observation/Assessment score: 9
Number of residents reviewed for wandering: 3
Duration missing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Resident #2's nurse on the day of elopement, interviewed regarding lack of knowledge about elopement risk |
| Director of Nursing | Director of Nursing | Interviewed about facility policies, risk assessments, and monitoring procedures related to Resident #2's elopement |
| Activities Director | Activities Director | Interviewed about lack of therapeutic interventions for Resident #2 |
Inspection Report
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
The inspection was conducted as a standard survey to assess compliance with health and safety regulations at Eagle Ridge Post Acute.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 68
Deficiencies: 5
Date: Feb 13, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, staffing, and treatment at Eagle Ridge Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide adequate clean linens consistently, failure to ensure timely assistance with activities of daily living for residents, failure to provide timely treatment and care for acute pain resulting in delayed surgery, failure to monitor and document pain management properly, and failure to maintain sufficient nursing staff to meet resident needs.
Deficiencies (5)
Failed to ensure residents had adequate access to clean bath linens at all times.
Failed to ensure one resident received timely assistance with wheelchair positioning, clothing, and eye cleanliness.
Failed to provide timely treatment and care for one resident with severe acute pain, resulting in delayed ultrasound and surgery for testicular torsion.
Failed to monitor and document pain management for one resident, including failure to assess pain every shift.
Failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed call light response and prolonged wait times for assistance.
Report Facts
Residents requiring assistance with bathing: 63
Residents requiring assistance with dressing: 62
Residents requiring assistance with transferring: 52
Residents requiring assistance with toileting: 63
Residents requiring assistance with eating: 38
Resident census: 68
Pain medication administrations for Resident #11 on 2/10/2020: 5
Pain medication administrations for Resident #11 on 2/11/2020: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Interviewed regarding linen issues and QAPI plan | |
| Director of Nursing (DON) | Director of Nursing | Provided policies, interviewed about ADL care, pain management, and staffing |
| Certified Nurse Aide (CNA) #1 | Certified Nurse Aide | Interviewed about Resident #46 care and linen stocking |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed about Resident #46 care |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Interviewed about Resident #11 care and pain management |
| Registered Nurse (RN) #2 | Registered Nurse | Interviewed about Resident #11 pain and care |
| Nursing Clinical Coordinator (NCC) #1 | Nursing Clinical Coordinator | Interviewed about Resident #11 ultrasound scheduling |
| Nursing Clinical Coordinator (NCC) #2 | Nursing Clinical Coordinator | Interviewed about Resident #11 ultrasound scheduling and order processing |
| Certified Nurse Aide (CNA) #4 | Certified Nurse Aide / Transporter and Scheduler | Interviewed about scheduling Resident #11 ultrasound |
| Certified Nurse Aide (CNA) #3 | Certified Nurse Aide | Interviewed about staffing shortages and workload |
| Certified Nurse Aide (CNA) #5 | Certified Nurse Aide | Interviewed about staffing shortages and call light delays |
| Certified Nurse Aide (CNA) #6 | Certified Nurse Aide | Interviewed about staffing shortages and call light delays |
| Medical Director (MD) | Medical Director | Interviewed about Resident #11 care and ultrasound order |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 13, 2018
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident safety, environment, medication storage, infection control, and record accuracy.
Findings
The facility was found deficient in maintaining a sanitary and safe environment, ensuring proper fall prevention measures, accurate resident weight documentation, proper medication storage, and infection control practices. Several environmental hazards, malfunctioning call lights, improper vaccine storage, inaccurate weight records, and cross-contamination risks with blood glucose monitoring devices were identified.
Deficiencies (5)
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly interior in three hallways.
Failed to ensure the resident's environment remained free from accident hazards, specifically call light placement and functionality for Resident #45.
Failed to ensure all drugs and biologicals were properly stored in medication refrigerators, including improper storage of vaccines in dormitory style refrigerators at incorrect temperatures.
Failed to ensure accuracy and timeliness of resident weight documentation for Residents #45 and #63.
Failed to ensure infection control standards were followed for blood glucose monitoring devices, including improper disinfection and storage leading to contamination risk.
Report Facts
Falls: 5
Resident weight discrepancies: 2
Medication refrigerators inspected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in infection control deficiency related to blood glucose monitoring device contamination. |
| CNA #5 | Certified Nurse Aide | Interviewed regarding call light placement and fall risk for Resident #45. |
| CNA #4 | Certified Nurse Aide | Interviewed regarding call light use and fall risk for Resident #45. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding call light use and fall risk for Resident #45. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including call light placement, vaccine storage, weight documentation, and infection control. |
| DM | Dietary Manager | Interviewed regarding resident weight documentation discrepancies. |
| Transportation Director | Certified Nurse Aide | Assisted Resident #45 during call light malfunction incident. |
| Maintenance Staff #1 | Interviewed regarding maintenance issues and repairs. | |
| Maintenance Staff #2 | Interviewed regarding maintenance issues and repairs. | |
| Housekeeper #1 | Interviewed regarding housekeeping deficiencies. |
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