Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Colorado average
Colorado average: 5.2 deficiencies/year
Deficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 4, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate range of motion care, inadequate treatment for residents with mental disorders, insufficient hospice service coordination, and lack of an effective antibiotic stewardship program.
Deficiencies (4)
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for a resident with limited ROM, including lack of physician orders and care plan interventions for a palm protector.
F 0742: The facility failed to provide appropriate treatment and services to residents with mental disorders to attain the highest practicable mental and psychosocial well-being, including failure to monitor depression and suicidal ideation and ineffective behavioral interventions.
F 0849: The facility failed to ensure hospice services met professional standards, including lack of effective communication and documentation of hospice care visits in the resident's medical record.
F 0881: The facility failed to implement an effective antibiotic stewardship program, including failure to track and monitor long-term antibiotic use for residents and lack of documentation justifying prolonged antibiotic therapy.
Report Facts
Sample residents reviewed: 29
Residents reviewed for restorative services: 3
Residents reviewed for mental health: 5
Residents reviewed for hospice services: 3
Residents reviewed for antibiotic use: 5
BIMS score: 15
BIMS score: 3
BIMS score: 12
BIMS score: 1
Antibiotic dosage: 250
Antibiotic dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding application of braces and palm protectors for Resident #43. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding care routines for Resident #43's palm protector. |
| RN #2 | Registered Nurse | Interviewed regarding physician orders for Resident #43. |
| OT #1 | Occupational Therapist | Interviewed regarding contracture measurements and therapy for Resident #43. |
| Interim Director of Nursing | Director of Nursing | Interviewed regarding care plan and communication processes for Resident #43 and hospice services. |
| CNA #2 | Certified Nurse Aide | Interviewed regarding knowledge of Resident #70's depression and suicidal ideation. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #70's behaviors and antibiotic use for Resident #16. |
| Social Services Director | Social Services Director | Interviewed regarding mental health assessments and interventions for Residents #70 and #10. |
| CNA #3 | Certified Nurse Aide | Interviewed regarding hospice care provision for Resident #8. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding hospice services and communication for Resident #8. |
| Hospice RN | Registered Nurse | Interviewed regarding hospice documentation and communication with facility. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding antibiotic stewardship program and monitoring. |
| Nursing Home Administrator | Administrator | Interviewed regarding antibiotic stewardship policy and facility procedures. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Good Samaritan Society -- Fort Collins Village nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate care to maintain or improve residents' range of motion, failure to provide adequate treatment and services for residents with mental disorders or psychosocial adjustment difficulties, failure to ensure hospice services met professional standards, and failure to implement an effective antibiotic stewardship program.
Deficiencies (4)
Failure to provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility.
Failure to provide appropriate treatment and services to residents with mental disorder or psychosocial adjustment difficulty.
Failure to arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for hospice services.
Failure to implement a program that monitors antibiotic use.
Report Facts
Residents reviewed: 29
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
BIMS scores: 15
BIMS scores: 3
BIMS scores: 12
BIMS scores: 3
BIMS scores: 10
BIMS scores: 1
Antibiotic order date: 2022
Antibiotic order date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding Resident #43's palm protector use and care plan. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #43's palm protector application and care. |
| RN #2 | Registered Nurse | Interviewed regarding absence of physician's order for Resident #43's brace or palm protector. |
| OT #1 | Occupational Therapist | Interviewed regarding Resident #43's contracture and therapy interventions. |
| Interim Director of Nursing | Director of Nursing | Interviewed regarding care plan and communication for Resident #43's brace and palm protector. |
| CNA #2 | Certified Nurse Aide | Interviewed regarding familiarity with Resident #70 and behaviors. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #70's behaviors and depression. |
| Social Services Director | Social Services Director | Interviewed regarding assessment and interventions for Resident #70 and Resident #10. |
| CNA #3 | Certified Nurse Aide | Interviewed regarding hospice care for Resident #8. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding hospice services for Resident #8. |
| Hospice RN | Registered Nurse | Interviewed regarding hospice documentation and communication for Resident #8. |
| Interim Director of Nursing | Director of Nursing | Interviewed regarding hospice services and communication for Resident #8. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding antibiotic use for Resident #16. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding antibiotic stewardship program and monitoring. |
| Nursing Home Administrator | Administrator | Interviewed regarding antibiotic stewardship program and monitoring. |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards related to food storage and preparation, infection prevention and control, antibiotic stewardship, and immunization policies in a nursing home facility.
Findings
The facility failed to ensure food was properly labeled and dated in nourishment rooms and timely inspection of the ice machine and filter. Infection control practices were inadequate, including improper cleaning and delayed reporting of gastrointestinal symptoms leading to norovirus spread. The antibiotic stewardship program was deficient in monitoring and appropriate use of antibiotics. The facility also failed to properly implement pneumococcal and influenza vaccination policies for several residents.
Deficiencies (4)
F0812: The facility failed to store, prepare, distribute and serve food in a sanitary manner, including unlabeled and expired food items in nourishment rooms and lack of timely ice machine and filter inspections.
F0880: The facility failed to maintain infection control standards during cleaning and failed to timely report gastrointestinal symptoms of Resident #17, contributing to norovirus spread.
F0881: The facility failed to implement an antibiotic stewardship program ensuring clinical signs and culture results before antibiotic administration for Residents #7, #16, and #5.
F0883: The facility failed to develop and implement policies and procedures for pneumococcal and influenza vaccinations, including failure to offer or document vaccinations or declinations for multiple residents.
Report Facts
Residents affected: 31
Date survey completed: Jan 9, 2024
Water filter change interval: 12
Antibiotic course duration: 10
Antibiotic course duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA #1 | Maintenance Assistant/Housekeeper | Named in infection control deficiency related to improper glove use and cleaning practices |
| Director of Nursing | Director of Nursing | Interviewed regarding immunization policies and resident vaccination status |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices, norovirus outbreak, and antibiotic stewardship |
| RN #3 | Registered Nurse | Interviewed regarding reporting of resident symptoms |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards related to food storage and handling, infection prevention and control, antibiotic stewardship, and immunization policies at the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to properly label and date food items in nourishment rooms, inadequate cleaning and inspection of ice machine and water filter, lapses in infection control practices including improper glove use and delayed reporting of gastrointestinal symptoms leading to norovirus spread, failure to implement an effective antibiotic stewardship program, and failure to properly implement pneumococcal and influenza vaccination policies and procedures.
Deficiencies (6)
Failed to ensure food was labeled and dated in nourishment rooms.
Failed to ensure timely inspection and cleaning of ice machine and ice machine water filter.
Failed to maintain infection control standards when cleaning resident rooms and bathrooms.
Failed to timely report gastrointestinal symptoms of Resident #17 to infection preventionist and physician, contributing to norovirus spread.
Failed to implement an antibiotic stewardship program ensuring appropriate antibiotic use and monitoring.
Failed to implement policies and procedures to ensure pneumococcal and influenza vaccinations were offered, documented, and administered according to CDC guidelines.
Report Facts
Residents affected: 31
Antibiotic use sample size: 29
Residents reviewed for immunizations: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA #1 | Maintenance Assistant / Housekeeper | Named in infection control deficiency related to improper glove use and cleaning practices |
| Director of Nursing | Director of Nursing | Interviewed regarding vaccination policies and resident immunization status |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices, norovirus outbreak, and antibiotic stewardship |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding reporting of resident symptoms |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding housekeeping practices and education provided to MA #1 |
| Nursing Home Administrator | Nursing Home Administrator | Provided facility policies and procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 9, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's infection prevention and control program, specifically regarding cleaning practices and the handling of a resident with gastrointestinal symptoms.
Complaint Details
The complaint investigation revealed that housekeeping staff did not perform proper hand hygiene or glove changes during cleaning, and personal items were handled improperly. Resident #17 had gastrointestinal symptoms starting 11/25/23, but the facility failed to notify the infection preventionist and physician until 11/27/23, resulting in norovirus spreading to 31 residents.
Findings
The facility failed to maintain an effective infection control program, including improper cleaning practices by housekeeping staff and delayed reporting of gastrointestinal symptoms of Resident #17, which contributed to the spread of norovirus affecting 31 residents.
Deficiencies (2)
Failure to ensure professional standards of infection control were followed when cleaning resident rooms and bathrooms.
Failure to follow infection control program when Resident #17 had gastrointestinal symptoms, including delayed notification to the infection preventionist and physician.
Report Facts
Residents affected by norovirus: 31
Date of survey completion: Jan 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA #1 | Maintenance Assistant and Housekeeper | Named in infection control deficiencies related to improper glove use and cleaning practices. |
| Infection Preventionist | Interviewed regarding infection control failures and education provided. | |
| Maintenance Supervisor | Interviewed regarding housekeeping oversight and education provided to staff. | |
| Registered Nurse #3 | Registered Nurse | Interviewed about reporting procedures for residents with gastrointestinal symptoms. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 9, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program and to assess compliance with infection control standards, including the handling of a resident with gastrointestinal symptoms.
Findings
The facility failed to maintain proper infection control practices during cleaning and failed to timely report gastrointestinal symptoms of Resident #17 to the infection preventionist and physician, which contributed to the spread of norovirus to 31 residents.
Deficiencies (2)
F 0880: The facility failed to ensure professional standards of infection control were followed when cleaning resident rooms and bathrooms, including improper glove use and handling of resident personal items.
F 0880: The facility failed to timely notify the physician and infection preventionist when Resident #17 first exhibited gastrointestinal symptoms, contributing to the spread of norovirus.
Report Facts
Residents affected by norovirus: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA #1 | Maintenance Assistant and Housekeeper | Named in infection control deficiencies related to improper glove use and cleaning practices |
| IP | Infection Preventionist | Interviewed regarding infection control practices and delayed reporting of Resident #17's symptoms |
| MS | Maintenance Supervisor | Interviewed regarding housekeeping practices and provided education to MA #1 |
| RN #3 | Registered Nurse | Interviewed about reporting procedures for residents with nausea, vomiting, or diarrhea |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 21, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication error rates exceeding the acceptable threshold of 5 percent.
Complaint Details
The complaint investigation found the medication error rate exceeded 5%, with errors substantiated involving incorrect medication dosage and unauthorized medication application.
Findings
The facility failed to maintain a medication error rate of 5% or less, with two errors out of 34 opportunities resulting in a 5.88% error rate. Errors included administering twice the ordered dose of Zyrtec to one resident and applying an unapproved medication (Biofreeze) without a physician's order to another resident.
Deficiencies (2)
F 0759: The facility failed to maintain a medication error rate of 5% or less, with two errors out of 34 opportunities. One error involved administering 10 mg of Zyrtec instead of the ordered 5 mg to Resident #21.
F 0759: The facility applied Biofreeze to Resident #19 without a physician's order, despite having orders for Icy Hot Cream and lidocaine patch for pain management.
Report Facts
Medication error rate: 5.88
Medication administration opportunities: 34
Errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication error findings for incorrect medication dose and unauthorized medication application |
| Director of Nursing | Interviewed regarding medication administration expectations | |
| Administrator | Interviewed regarding medication administration expectations |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 21, 2022
Visit Reason
The inspection was conducted to assess the facility's medication administration practices and ensure medication error rates were not 5 percent or greater.
Findings
The facility failed to maintain a medication error rate of 5% or less, with two errors out of 34 opportunities resulting in a 5.88% medication error rate involving two residents. Deficiencies included administering twice the ordered dose of medication and applying a topical treatment without a physician's order.
Deficiencies (2)
Administered 10 mg of Zyrtec to Resident #21, twice the ordered dose of 5 mg.
Applied Biofreeze to Resident #19's lower back without a physician's order.
Report Facts
Medication error rate: 5.88
Medication administration opportunities: 34
Errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication error findings involving incorrect medication dose and unauthorized topical application |
| Director of Nursing | Interviewed regarding medication administration expectations | |
| Administrator | Interviewed regarding medication administration expectations |
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