Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with providing appropriate treatment and services to residents diagnosed with dementia, specifically focusing on one resident's wandering behavior and dementia care.
Findings
The facility failed to ensure that residents with dementia received appropriate person-centered care to prevent wandering into other residents' rooms. Staff failed to monitor and engage the resident adequately, resulting in unsafe wandering behaviors and insufficient documentation of these behaviors.
Deficiencies (1)
Failed to provide appropriate treatment and services to a resident diagnosed with dementia to prevent wandering into other residents' rooms.
Report Facts
Residents reviewed for dementia care: 4
Residents affected: 1
BIMS score: 3
Observation duration: 94
Observation duration: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Observed and reported on Resident #4's wandering behavior and interventions. | |
| Licensed Practical Nurse (LPN) #1 | Observed Resident #4 wandering and redirected him during observations. | |
| Certified Nurse Aide (CNA) #2 | Found Resident #4 asleep in another resident's bed and redirected him. | |
| Licensed Practical Nurse (LPN) #2 | Provided dementia care and reported on Resident #4's wandering and aggressive behaviors. | |
| Director of Nursing (DON) | Interviewed regarding staff training and monitoring of Resident #4's wandering behavior. | |
| Social Services Director (SSD) | Interviewed about care plan reviews and documentation of wandering behaviors. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate treatment and services to residents diagnosed with dementia, specifically focusing on Resident #4's wandering behavior and dementia care.
Complaint Details
The complaint investigation focused on Resident #4, who was diagnosed with dementia and exhibited wandering behavior, including entering other residents' rooms and sleeping in their beds. The facility failed to implement effective interventions and documentation to manage these behaviors. Staff interviews confirmed inadequate monitoring and documentation of the resident's wandering and aggressive behaviors.
Findings
The facility failed to develop and implement effective person-centered dementia management interventions to prevent Resident #4 from wandering into other residents' rooms. Staff failed to monitor and engage the resident in meaningful activities, document wandering behaviors, and ensure resident safety, resulting in minimal harm or potential for actual harm.
Deficiencies (1)
F 0744: The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in wandering into other residents' rooms and inadequate supervision. Staff did not effectively monitor or engage the resident to prevent unsafe wandering behaviors.
Report Facts
Residents reviewed for dementia care: 4
Resident #4 BIMS score: 3
Observation duration: 94
Observation duration: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #4's wandering and aggressive behaviors |
| LPN #1 | Licensed Practical Nurse | Observed and redirected Resident #4 during wandering incidents |
| LPN #2 | Licensed Practical Nurse | Interviewed about dementia training and Resident #4's wandering and aggressive behaviors |
| CNA #2 | Certified Nurse Aide | Interviewed about Resident #4's wandering and aggression |
| Director of Nursing | Director of Nursing | Interviewed regarding staff training and monitoring of Resident #4 |
| Social Services Director | Social Services Director | Interviewed about care plan reviews and documentation of wandering behaviors |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 1, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident abuse, involuntary seclusion, use of psychotropic medications, wound care, medication errors, medication storage, and COVID-19 vaccination follow-up at the facility.
Complaint Details
The complaint investigation substantiated multiple deficiencies including resident abuse, improper seclusion practices, psychotropic medication misuse, wound care failures, medication errors, improper vaccine storage, and failure to offer COVID-19 vaccination.
Findings
The facility was found to have substantiated incidents of resident-to-resident physical abuse, failure to ensure proper documentation and least restrictive approaches for involuntary seclusion, inadequate monitoring and documentation of psychotropic medication use, failure to provide wound care per updated physician orders, medication administration errors, improper vaccine storage, and failure to follow up on COVID-19 vaccination consent and administration.
Deficiencies (7)
F0600: The facility failed to protect residents from physical abuse by other residents, substantiated for three residents involved in altercations causing injuries and inadequate staff supervision.
F0603: The facility failed to ensure one resident was not subjected to involuntary seclusion without proper consent, documentation, or least restrictive approach evaluation.
F0605: The facility failed to adequately identify and monitor target behaviors for psychotropic medications, provide resident-specific interventions, and justify medication changes for three residents.
F0684: The facility failed to provide wound care per physician's updated orders for one resident, continuing an outdated dressing despite new orders.
F0759: The facility failed to ensure medication administration accuracy, including dispensing incorrect medication and incorrect dosing measurement for two medications.
F0761: The facility failed to store vaccines properly, storing them in a dormitory-style refrigerator at an unsafe temperature below recommended range.
F0887: The facility failed to follow up with a resident and/or representative to offer and administer COVID-19 vaccination and failed to document vaccine offers or education.
Report Facts
Medication error rate: 8
Medihoney gel applications: 21
Vaccines in refrigerator: 21
BIMS scores: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Nurse (WCN) | Named in wound care deficiency for Resident #57 regarding failure to update wound care orders and follow physician instructions. | |
| Registered Nurse (RN) #1 | Named in medication administration errors involving dispensing incorrect medication and incorrect dosing measurement. | |
| Infection Preventionist (IP) | Named in vaccine storage deficiency and COVID-19 vaccination follow-up deficiency. | |
| Director of Nursing (DON) | Named in multiple deficiencies including abuse investigations, medication administration, vaccine storage, and COVID-19 vaccination follow-up. | |
| Physician/Wound Care Physician (WCP) | Named in wound care deficiency for Resident #57 regarding verbal orders and failure to ensure proper order documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident physical abuse incidents within the facility involving multiple residents.
Complaint Details
The complaint investigation substantiated abuse between residents. The facility failed to ensure adequate supervision, including failure to replace a one-on-one caregiver during breaks, and did not implement sufficient person-centered interventions after altercations. Multiple incidents were documented on 2/18/25, 2/19/25, and 3/24/25 involving physical altercations and injuries.
Findings
The facility substantiated multiple incidents of resident-to-resident physical abuse involving Residents #86, #48, #93, and #84. The investigations revealed failures in supervision, inadequate implementation of care plans, and insufficient staff education to prevent abuse. Injuries were noted but were generally minimal harm or potential for actual harm.
Deficiencies (1)
F 0600: The facility failed to protect residents from physical abuse by other residents, including incidents between Residents #86 and #48, and Resident #84 towards Resident #93.
Report Facts
Residents reviewed for abuse: 35
Residents involved in abuse incidents: 6
One-on-one caregiver supervision duration: 72
BIMS scores: 4
BIMS scores: 5
BIMS scores: 3
BIMS scores: 7
Injury measurements: 0.3
Injury measurements: 0.1
Injury measurements: 1
Injury measurements: 0.1
Injury measurements: 0.2
Injury measurements: 0.2
Injury measurements: 2
Injury measurements: 1.5
Injury measurements: 3
Injury measurements: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted due to complaints and investigations of resident-to-resident physical abuse incidents involving multiple residents at the facility.
Complaint Details
The complaint investigation was substantiated. Abuse was substantiated involving physical altercations between Residents #86 and #48 on 2/18/25 and 2/19/25, and between Resident #84 and Resident #93 on 3/24/25.
Findings
The facility failed to protect residents from physical abuse by other residents, with substantiated abuse incidents involving Residents #86, #48, and #93. The facility did not consistently implement person-centered interventions or ensure adequate supervision, resulting in multiple altercations and injuries. Staff education and intervention processes were inadequate to prevent recurrence.
Deficiencies (1)
Failure to protect residents from physical abuse by other residents, including incidents between Residents #86 and #48, and Resident #84 towards Resident #93.
Report Facts
Residents reviewed for abuse: 35
Residents affected: 3
One-on-one caregiver supervision duration: 72
BIMS scores: 4
BIMS scores: 5
BIMS scores: 3
BIMS scores: 7
Injury measurements: 0.3
Injury measurements: 0.1
Injury measurements: 1
Injury measurements: 0.1
Injury measurements: 0.2
Injury measurements: 0.2
Injury measurements: 2
Injury measurements: 1.5
Injury measurements: 3
Injury measurements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Named in relation to failure to ensure replacement of one-on-one caregiver and inadequate staff education on resident supervision |
| Social Services Director | SSD | Interviewed regarding resident care plans and interventions related to resident behaviors and abuse prevention |
| Certified Nurse Aide #2 | CNA | Interviewed regarding resident behaviors and supervision |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding resident behaviors and unit assignments |
| Certified Nurse Aide #3 | CNA | Interviewed regarding access to care plans and observations of resident behaviors |
| Registered Nurse #3 | RN | Interviewed regarding documentation of resident behaviors and interventions |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 1, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident abuse, involuntary seclusion, use of psychotropic medications, wound care, medication errors, medication storage, and COVID-19 vaccination procedures at the facility.
Complaint Details
The complaint investigation substantiated abuse between residents, improper use of psychotropic medications, medication errors, improper vaccine storage, failure to provide wound care per orders, and failure to offer COVID-19 vaccination to a resident.
Findings
The facility failed to protect residents from physical abuse by other residents, failed to ensure proper documentation and least restrictive approaches for involuntary seclusion and psychotropic medication use, failed to provide wound care per physician orders, had medication errors exceeding 5%, improperly stored vaccines in a dormitory style refrigerator, and failed to properly offer and document COVID-19 vaccinations for a resident.
Deficiencies (7)
Failed to protect residents #48, #86, and #93 from physical abuse by other residents.
Failed to ensure resident #79 was free from involuntary seclusion and lacked required documentation for secure unit placement.
Failed to ensure residents #57, #10, and #51 were free from chemical restraint and received least restrictive psychotropic medication use with adequate monitoring and documentation.
Failed to provide wound care per physician orders for Resident #57, continuing to apply discontinued Medihoney gel instead of calcium alginate with silver dressing.
Medication error rate was 8%, exceeding the 5% threshold, including dispensing incorrect medication and incorrect dosing measurement.
Vaccines were stored in a dormitory style refrigerator at 34°F, below the recommended 36-46°F range, risking vaccine efficacy.
Failed to offer and properly document COVID-19 vaccination for Resident #69, including lack of follow-up with resident or representative.
Report Facts
Medication error rate: 8
Resident census sample: 35
Medihoney gel application dates: 21
BIMS scores: 1
Refrigerator temperature: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered medications including incorrect dosing and medication; interviewed regarding medication administration. |
| WCN | Wound Care Nurse | Responsible for wound care and entering wound care orders; interviewed regarding wound care discrepancies. |
| DON | Director of Nursing | Interviewed regarding facility policies, medication administration, wound care, and COVID-19 vaccination procedures. |
| IP | Infection Preventionist | Interviewed regarding vaccine storage and COVID-19 vaccination procedures. |
| WCP | Wound Care Physician | Interviewed regarding wound care orders and treatment for Resident #57. |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 14, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, including housekeeping and nursing staff practices related to wound care, cleaning, and disinfection.
Findings
The facility failed to maintain an effective infection control program, with deficiencies observed in wound care practices, housekeeping hand hygiene, glove use, cleaning of high-touch surfaces, adherence to disinfectant dwell times, and disinfection of shared medical equipment. These failures posed a minimal harm or potential for actual harm to residents.
Deficiencies (5)
RN #1 failed to use a new piece of gauze for each wipe over the wound bed during cleaning.
Housekeeping staff failed to engage in proper hand hygiene and glove changes between resident rooms and different areas within rooms.
Housekeeping staff failed to disinfect high frequency touch areas and did not adhere to surface disinfectant dwell times.
Nursing staff failed to disinfect shared equipment (vitals machines and lifts) between residents.
Shared medical equipment was observed to be dirty and not properly cleaned or disinfected.
Report Facts
Units with infection control failures: 3
Disinfectant dwell time: 60
Disinfectant dwell time: 300
Disinfectant dwell time: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed providing wound care with improper gauze use. |
| LPN #1 | Licensed Practical Nurse | Observed failing to properly disinfect vitals machine between residents. |
| HSK #1 | Housekeeper | Observed failing to perform hand hygiene, glove changes, and proper surface disinfection. |
| HSK #2 | Housekeeper | Observed failing to adhere to surface disinfectant dwell times and glove changes. |
| HSK #3 | Housekeeper | Observed failing to adhere to surface disinfectant dwell times and glove changes. |
| CNA #4 | Certified Nursing Assistant | Observed failing to disinfect shared medical equipment properly. |
| CNA #5 | Certified Nursing Assistant | Observed failing to disinfect shared medical equipment properly. |
| HLM | Housekeeping and Laundry Manager | Interviewed regarding housekeeping procedures and deficiencies. |
| IP | Infection Preventionist | Interviewed regarding infection control practices and cleaning products. |
| DON | Director of Nursing | Interviewed regarding wound care procedures. |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 14, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, including housekeeping and nursing practices related to wound care and cleaning procedures.
Findings
The facility failed to maintain an effective infection control program, with deficiencies in housekeeping staff hand hygiene, glove use, cleaning and disinfecting high-touch surfaces, adherence to disinfectant dwell times, and nursing staff infection control during wound care. Shared medical equipment was also not properly disinfected between residents.
Deficiencies (2)
F 0880: The facility failed to provide and implement an infection prevention and control program. Housekeeping staff did not engage in proper hand hygiene, failed to change gloves appropriately, and did not disinfect high-touch surfaces or shared equipment correctly.
Nursing staff failed to follow proper wound care procedures by using the same piece of gauze multiple times on open wounds, risking contamination.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed providing improper wound care by reusing gauze on wounds. |
| HSK #1 | Housekeeper | Observed failing to perform hand hygiene, changing gloves properly, and disinfecting surfaces. |
| HSK #2 | Housekeeper | Observed not adhering to disinfectant dwell times and glove changes. |
| HSK #3 | Housekeeper | Observed improper cleaning techniques and failure to disinfect high-touch areas. |
| CNA #4 | Certified Nursing Assistant | Failed to disinfect shared medical equipment properly. |
| CNA #5 | Certified Nursing Assistant | Failed to disinfect shared medical equipment properly. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident physical abuse involving two residents at the facility.
Complaint Details
The complaint investigation substantiated that Resident #4 physically abused Resident #3 on 3/1/23 at approximately 7:20 p.m. The incident involved Resident #4 hitting Resident #3 with a belt, resulting in injuries to both residents. Both residents and multiple staff were interviewed, and the facility initiated monitoring and interventions following the incident.
Findings
The facility failed to ensure residents were free from abuse, specifically failing to prevent an incident where Resident #4 physically abused Resident #3 by striking him with a belt. Both residents sustained injuries and were separated and closely monitored following the incident.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Specifically, Resident #4 struck Resident #3 with a belt causing injury. The facility did not prevent this incident of resident-to-resident abuse.
Report Facts
Injury measurement: 1.5
Injury measurement: 3
Injury measurement: 3
Injury measurement: 3
Medication dosage: 650
Pain level: 3
Monitoring frequency: 15
BIMS score: 3
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Conducted assessments and neurological checks on Residents #3 and #4 after the altercation |
| LPN #2 | Licensed Practical Nurse | Reported and assisted with care following the resident-to-resident altercation |
| CNA #1 | Certified Nurse Aide | Discovered the injured residents and reported the incident to nursing staff |
| DON | Director of Nursing | Reviewed incident and care plans, interviewed staff and residents |
| NHA | Nursing Home Administrator | Interviewed regarding the incident and facility response |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of physical abuse between two residents (#3 and #4) at the facility.
Complaint Details
The complaint investigation was substantiated. The incident involved Resident #4 hitting Resident #3 with a belt after Resident #3 caused emotional distress to Resident #4. Both residents were assessed and monitored following the incident.
Findings
The facility failed to prevent an incident of physical abuse where Resident #4 struck Resident #3 with a belt, resulting in minor injuries to both residents. The incident was investigated, residents were separated, monitored, and care plans were updated accordingly.
Deficiencies (1)
Failed to protect residents from physical abuse by another resident.
Report Facts
Skin tear measurement: 1.5
Skin tear measurement: 3
Pain medication dosage: 650
Pain level: 3
BIMS score: 3
BIMS score: 6
15-minute checks duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Conducted assessments and neurological checks on Residents #3 and #4 after the altercation |
| CNA #1 | Certified Nurse Aide | Discovered the incident and reported it to the nurse on duty |
| LPN #2 | Licensed Practical Nurse | Assisted with wound care and reported incident details |
| RN #4 | Registered Nurse | Concluded Resident #4 hit Resident #3 with the belt buckle |
| NHA | Nursing Home Administrator | Interviewed regarding the incident and facility response |
| DON | Director of Nursing | Interviewed regarding the incident and facility response |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 30, 2022
Visit Reason
The inspection was conducted to assess compliance with resident dignity rights and infection prevention and control practices, including COVID-19 visitor screening and catheter care.
Findings
The facility was found deficient in maintaining resident dignity by failing to cover a urinary catheter drainage bag for Resident #14 and in infection control by inadequate visitor COVID-19 screening and allowing a catheter drainage bag to rest on the floor, posing a potential infection risk.
Deficiencies (3)
Failed to ensure dignity by not covering Resident #14's urinary catheter drainage bag.
Failed to conduct thorough visitor screening for COVID-19 on three of four survey days.
Allowed Resident #14's catheter drainage bag to rest on the floor, risking contamination.
Report Facts
Days visitor screening deficient: 3
Residents reviewed for urinary catheters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Stated catheter drainage bag should be covered and not touch the floor. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Noted catheter bag should be covered and not touch the floor for sanitary reasons. |
| Director of Nursing | Director of Nursing | Stated expectation for staff to cover catheter bags and conduct visitor screening. |
| Administrator | Administrator | Stated catheter bags should be covered and visitor screening signs and symptoms should be reviewed. |
| Infection Control Preventionist | Infection Control Preventionist | Acknowledged staff did not ask COVID-19 screening questions for visitors on three days. |
| Infection Control Nurse | Infection Control Nurse | Stated catheter bag should not be on the floor due to infection risk. |
| Recreation Staff #2 | Recreation Staff | Stated catheter drainage bag should be covered for respect and dignity. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 30, 2022
Visit Reason
The inspection was conducted to investigate complaints related to dignity and infection control practices, specifically regarding the handling and coverage of a resident's urinary catheter drainage bag and visitor COVID-19 screening procedures.
Complaint Details
The complaint investigation focused on dignity issues related to catheter bag coverage and infection control concerns including visitor COVID-19 screening and catheter bag placement. The findings substantiated failures in dignity and infection prevention practices.
Findings
The facility failed to ensure dignity by not consistently covering a resident's urinary catheter drainage bag and failed to implement thorough visitor COVID-19 screening for three of four survey days. Additionally, the facility allowed a catheter drainage bag to rest on the floor, posing a potential infection risk.
Deficiencies (2)
F 0550: The facility failed to ensure dignity by not covering the urinary catheter drainage bag for Resident #14 during multiple observations.
F 0880: The facility failed to conduct thorough visitor COVID-19 screening for three of four survey days and allowed Resident #14's catheter drainage bag to rest on the floor, risking infection.
Report Facts
Days visitor screening incomplete: 3
Residents sampled for catheter care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Stated catheter drainage bag should be covered and not touch the floor; confirmed catheter bag touching floor during observation. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Noted catheter bag should be covered for dignity and infection control; stated catheter bag should not touch floor. |
| Director of Nursing | Director of Nursing | Stated expectation for catheter bag coverage and visitor screening; emphasized infection control concerns with catheter bag touching floor. |
| Administrator | Administrator | Stated catheter bag should be covered for dignity and acknowledged infection control risks with catheter bag on floor. |
| Infection Control Preventionist | Infection Control Preventionist | Acknowledged staff did not ask COVID-19 screening questions for visitors on three days; stated visitors should be educated on PPE and hand hygiene. |
| Infection Control Nurse | Infection Control Nurse | Stated catheter bag should not be on floor due to possible infection risk. |
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