Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
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: 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
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. |
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