Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and proper transfer methods for Resident #3, who sustained a tibia fracture and a fall while being transferred.
Complaint Details
The complaint investigation found that Resident #3, who required two-person assistance for transfers, sustained a tibia fracture of unknown origin likely during transfer and later slid out of a Hoyer lift due to improper sling size and transfer technique. The facility's investigation revealed inconsistent transfer methods, inadequate staff training, and failure to update care plans timely. The resident was nonverbal and dependent on staff for all ADLs and mobility.
Findings
The facility failed to ensure Resident #3 was properly supervised and transferred, resulting in a nondisplaced acute proximal tibia fracture and a fall from a Hoyer lift. Staff inconsistently used transfer methods and did not properly update or follow the resident's transfer care plan, leading to actual harm.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents reviewed: 5
Residents affected: 1
Date of initial bruise discovery: Jul 17, 2025
Date of fall: Oct 2, 2025
Sling sizes: 2
Number of CNAs trained post-incident: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Did initial assessment of Resident #3's bruise and interviewed during investigation |
| CNA #4 | Certified Nurse Aide | Discovered bruise on Resident #3 and alerted day shift nurse |
| CNA #6 | Certified Nurse Aide | Involved in Hoyer lift transfer when Resident #3 slid out of sling |
| RNA #1 | Restorative Nurse Aide | Assisted CNA #6 during Hoyer lift transfer observation |
| Director of Nursing | Director of Nursing | Notified of bruise, involved in staff education and transfer status decisions |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding transfer status and staff education |
| Primary Care Physician | Primary Care Physician | Examined bruise, ordered Xray confirming tibia fracture |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and proper transfer methods for Resident #3, who sustained injuries including a tibia fracture and a fall from a mechanical lift.
Complaint Details
The investigation was complaint-driven, focusing on Resident #3's injuries from inconsistent transfer methods and inadequate supervision. The complaint was substantiated with findings of actual harm.
Findings
The facility failed to ensure Resident #3 was consistently and properly transferred, resulting in a nondisplaced acute proximal tibia fracture and a fall from a Hoyer lift. Staff were not fully educated on proper transfer techniques and sling sizing, and the resident's care plan was not updated timely to reflect transfer needs.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, resulting in actual harm to Resident #3 who sustained a tibia fracture and a fall during transfers.
Report Facts
Residents affected: 1
Date of survey completion: Oct 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Conducted initial assessment of Resident #3's bruise and was interviewed regarding transfer status and care. |
| CNA #4 | Certified Nurse Aide | Discovered the bruise on Resident #3 and was interviewed about transfer practices. |
| CNA #6 | Certified Nurse Aide | Participated in Hoyer lift transfer observed during survey and interviewed about transfer technique. |
| RNA #1 | Restorative Nurse Aide | Assisted in Hoyer lift transfer observed during survey and interviewed about transfer technique. |
| DON | Director of Nursing | Notified about Resident #3's injuries, involved in staff education and transfer status decisions. |
| ADON | Assistant Director of Nursing | Involved in assessments, staff education, and transfer status communication. |
| PCP | Primary Care Physician | Examined Resident #3's bruise, ordered Xray, and provided medical opinions on injury cause. |
| NP | Nurse Practitioner | Interviewed regarding Resident #3's fracture and transfer status. |
| PTA #1 | Physical Therapist Assistant | Interviewed about therapy services and transfer protocols. |
| RN #1 | Registered Nurse | Assessed Resident #3 after fall and interviewed about sling use and education. |
| SSD | Social Services Director | Interviewed regarding incident and staff training. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to honor residents' rights to self-determination and choice, specifically related to relationship preferences of two residents with dementia.
Complaint Details
The complaint investigation found that Resident #6 and Resident #12, both with dementia, engaged in consensual kissing and holding hands, but the facility had not completed assessments to determine their ability to consent or addressed their relationship preferences in care plans.
Findings
The facility failed to assess, document, and care plan for the relationship preferences of two residents with cognitive impairments. Additionally, the facility failed to ensure proper labeling and storage of medications, specifically multiple use vials of Aplisol tuberculin, which were either past the recommended use date or unlabeled.
Deficiencies (2)
Failed to assess, document, and care plan Resident #12 and Resident #6's relationship preferences.
Failed to ensure multiple use vials of Aplisol tuberculin were labeled appropriately and discarded after 30 days.
Report Facts
Residents reviewed: 29
BIMS score: 11
BIMS score: 5
Date vial first accessed: 10
Days medication good for: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding residents' cognitive status and medication storage |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding residents' psychotropic medications and consent assessments |
| Registered Nurse #1 | Registered Nurse (RN) | Interviewed regarding residents' behaviors and cognitive status |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed regarding resident behaviors and medication storage |
| Certified Nurse Aide #2 | Certified Nurse Aide (CNA) | Interviewed regarding resident behaviors |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding residents' dementia and consent assessments |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding medication vial labeling and storage |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to support resident self-determination and choice, specifically related to residents' relationship preferences and medication storage practices.
Complaint Details
The complaint investigation focused on the facility's failure to support resident self-determination and proper medication storage. The incidents involved two residents with dementia engaging in consensual but inappropriate behavior that was not properly assessed or documented. Medication storage issues involved expired or unlabeled vials. The complaint was substantiated with findings of minimal harm.
Findings
The facility failed to assess, document, and care plan for two residents' relationship preferences, resulting in inappropriate behavior not properly addressed. Additionally, the facility failed to ensure proper labeling and storage of multiple-use medication vials in one of two medication rooms.
Deficiencies (2)
F 0561: The facility failed to honor residents' rights to self-determination by not assessing, documenting, or care planning for Resident #12 and Resident #6's relationship preferences, despite incidents of inappropriate behavior.
F 0761: The facility failed to ensure all drugs and biologicals were properly labeled and stored in locked compartments, specifically multiple-use vials of Aplisol tuberculin that were either past the recommended use date or unlabeled.
Report Facts
Residents reviewed: 29
Residents affected: 2
Medication vials observed: 2
BIMS score: 11
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding residents' behaviors and cognitive status |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding resident behaviors and medication storage |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding resident behaviors |
| Director of Nursing | Director of Nursing | Interviewed regarding residents' cognitive status and medication storage policies |
| Social Services Director | Social Services Director | Interviewed regarding residents' psychotropic medications and consent assessments |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding residents' behaviors and consent assessments |
| Infection Preventionist | Infection Preventionist | Interviewed regarding medication vial labeling and storage |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration, activities of daily living assistance, nutrition, pain management, food service, and infection control in a skilled nursing facility.
Findings
The facility was found deficient in timely medication administration, repositioning of residents at risk for pressure ulcers, providing appropriate diet modifications, managing pain adequately, following mechanically altered diet recipes, maintaining proper food storage temperatures, preventing cross-contamination in food handling, and enforcing mask use in the kitchen during a pandemic.
Deficiencies (6)
Failed to ensure medications were administered as ordered and timely for Resident #24.
Failed to provide necessary care and assistance for activities of daily living, including repositioning Resident #26 for an extended period of time.
Failed to ensure Resident #204 was assessed and provided the correct diet to meet nutrition needs and preferences.
Failed to manage pain appropriately for Resident #6, including reassessment and documentation of pain characteristics and interventions.
Failed to follow recipe modifications for mechanically altered diets, serving improperly prepared food.
Failed to store, prepare, distribute and serve food in a sanitary manner, including improper glove use, freezer malfunction, cross-contamination risk with ice machine, improper cold food temperatures, and failure to wear masks in the kitchen during a pandemic.
Report Facts
Residents in sample: 27
Medication administration time delay: 141
Repositioning interval: 270
Weight loss: 7.6
Pain level: 10
Pain level: 9
Pain level: 8
Freezer temperature: 41
Potato salad temperature: 53
Shrimp cocktail temperature: 51
Deli turkey temperature: 44.8
Watermelon temperature: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration and pain management findings |
| DON | Director of Nursing | Interviewed regarding medication administration, repositioning, pain management, and facility policies |
| CNA #2 | Certified Nurse Aide | Named in repositioning deficiency for Resident #26 |
| Cook #1 | Named in food preparation and food safety deficiencies | |
| Cook #2 | Named in food preparation and food safety deficiencies | |
| RD | Registered Dietitian | Named in nutrition and diet modification deficiencies |
| CNA #4 | Certified Nurse Aide | Named in pain management deficiency for Resident #6 |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 11, 2022
Visit Reason
Routine inspection of Grace Pointe Cont Care Sr Campus, Skilled Nursing to assess compliance with professional standards of quality, nutrition, pain management, food safety, and infection control.
Findings
The facility failed to ensure timely medication administration, proper repositioning of residents at risk for pressure ulcers, appropriate nutrition care and diet modifications, effective pain management, adherence to food safety standards including proper food handling and storage, and compliance with infection control mask-wearing policies in the kitchen.
Deficiencies (6)
F0658: The facility failed to ensure medications were administered as ordered and timely for Resident #24, with medications given late beyond the prescribed time window.
F0677: The facility failed to reposition Resident #26 for an extended period of 4.5 hours despite high risk for pressure ulcers and need for two-person assistance.
F0692: The facility failed to assess and provide the correct diet for Resident #204, not communicating updated diet orders to kitchen staff, resulting in inadequate food texture and utensil accommodations.
F0697: The facility failed to manage pain for Resident #6 after a fall, with inadequate reassessment, documentation, and follow-up despite ongoing moderate to severe pain and refusal of medication.
F0803: The facility failed to follow recipe modifications for mechanically altered diets, serving improperly chopped turkey instead of ground meat for residents on mechanical soft diets.
F0812: The facility failed to ensure sanitary food handling in the kitchen, including improper glove use, malfunctioning freezer with ice build-up, cross-contamination risk from improper ice scoop use, improper cold food holding temperatures, and failure of kitchen staff to wear masks during a pandemic.
Report Facts
Residents sampled: 27
Medication administration time: 141
Repositioning interval: 4.5
Weight loss: 7.6
Pain levels: 10
Freezer temperature: 41
Potato salad temperature: 53
Shrimp cocktail temperature: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration and pain management findings |
| CNA #2 | Certified Nurse Aide | Named in repositioning deficiency for Resident #26 |
| Cook #1 | Named in food preparation and food safety deficiencies | |
| Director of Nursing | DON | Interviewed regarding medication administration, repositioning, and pain management |
| Culinary Director | CD | Interviewed regarding food preparation, freezer issues, and ice scoop use |
| Registered Dietitian | RD | Interviewed regarding diet modifications and nutrition care |
| Nursing Home Administrator | NHA | Interviewed regarding facility policies and infection control |
| Certified Nurse Aide #4 | CNA | Interviewed regarding pain complaints of Resident #6 |
Inspection Report
Routine
Census: 31
Deficiencies: 8
Date: May 26, 2021
Visit Reason
The inspection was a routine survey to assess compliance with regulatory standards, including investigation of alleged violations, medication administration, wound care, activities, catheter care, medication error rates, food storage, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate injuries, medication administration errors, inadequate wound care and monitoring, failure to provide meaningful activities, lack of catheter care orders and documentation, improper food storage temperatures, and deficiencies in antibiotic stewardship program implementation.
Deficiencies (8)
Failed to thoroughly investigate how a skin tear occurred on Resident #11's right arm.
Failed to provide medication administration according to professional standards, including crushing capsules that should not be crushed and lack of dose amount for topical medication.
Failed to provide meaningful activities based on residents' preferences for Residents #20 and #17.
Failed to provide treatment and care according to orders and professional standards for Residents #17, #11, and #20, including inconsistent wound monitoring and lack of treatment orders.
Failed to have orders for catheter care and documentation to indicate catheter care was being provided for Resident #11.
Failed to ensure medication error rate was below 5%, with an 18.52% error rate observed.
Failed to store food at proper refrigerator temperatures, with refrigerator temperatures observed as high as 55°F.
Failed to ensure antibiotic stewardship program included monitoring and evaluation of prophylactic antibiotic use for Residents #22 and #7.
Report Facts
Residents reviewed: 31
Medication error rate: 18.52
Medication errors: 5
Medication administration opportunities: 27
Refrigerator temperature: 55
Refrigerator temperature: 50
Refrigerator temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication error findings and resident medication administration observations |
| RN #2 | Registered Nurse | Interviewed regarding skin assessments, wound monitoring, and medication administration |
| RN #3 | Registered Nurse | Interviewed regarding medication administration and wound care |
| DON | Director of Nursing | Interviewed regarding wound care, medication errors, catheter care, and antibiotic stewardship |
| WN | Wound Nurse | Interviewed regarding wound care and monitoring |
| CNA #1 | Certified Nurse Aide | Interviewed regarding skin issue reporting and activities |
| CNA #2 | Certified Nurse Aide | Observed assisting residents and interviewed regarding activities |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident activities and skin issue reporting |
| AA | Activity Assistant | Interviewed regarding resident activities and preferences |
| DM | Dietary Manager | Interviewed regarding refrigerator temperature and food disposal |
| ICRN | Infection Control Registered Nurse | Interviewed regarding antibiotic stewardship program |
Inspection Report
Routine
Deficiencies: 8
Date: May 26, 2021
Visit Reason
Routine inspection of Grace Pointe Cont Care Sr Campus, Skilled Nursing, to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate injuries, medication administration errors, inadequate activity programming, improper wound care and monitoring, lack of catheter care orders and documentation, medication error rate exceeding 5%, improper food storage temperatures, and deficiencies in antibiotic stewardship program.
Deficiencies (8)
F 0610: Facility failed to thoroughly investigate how a skin tear occurred on Resident #11's right arm.
F 0658: Facility failed to meet professional standards in medication administration for Residents #20, #11, and #7, including improper medication preparation, administration, and incomplete physician orders.
F 0679: Facility failed to provide meaningful activities based on residents' preferences for Residents #20 and #17.
F 0684: Facility failed to provide appropriate treatment and care according to orders and resident preferences for Residents #17, #11, and #20, including inconsistent wound monitoring and lack of treatment orders.
F 0690: Facility failed to consistently provide catheter care, treatment, and services to minimize urinary tract infection risk for Resident #11 due to lack of catheter care orders and documentation.
F 0759: Facility failed to ensure medication error rate was below 5%, with an 18.52% error rate observed among four residents.
F 0812: Facility failed to store food at proper refrigerator temperatures, with observed temperatures up to 55°F in the rehabilitation kitchen refrigerator.
F 0881: Facility failed to implement an antibiotic stewardship program that monitors antibiotic use, including evaluation and monitoring of prophylactic antibiotic use for Residents #22 and #7.
Report Facts
Medication error rate: 18.52
Refrigerator temperature: 55
Refrigerator temperature: 50
Refrigerator temperature: 48
Refrigerator temperature: 42
Skin tear length: 4
Medication dose: 150
Medication dose: 100
Medication dose: 8.6
Medication dose: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication errors and interviewed regarding medication administration. |
| RN #2 | Registered Nurse | Interviewed regarding skin assessments, wound monitoring, and medication administration. |
| RN #3 | Registered Nurse | Observed medication administration and interviewed regarding medication errors and wound care. |
| DON | Director of Nursing | Interviewed regarding wound care, medication administration, catheter care, and antibiotic stewardship. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding reporting of skin issues and activity involvement. |
| CNA #2 | Certified Nurse Aide | Observed assisting residents and interviewed regarding skin care. |
| CNA #3 | Certified Nurse Aide | Interviewed regarding activity participation and resident interactions. |
| WN | Wound Nurse | Interviewed regarding wound care and monitoring. |
| DM | Dietary Manager | Interviewed and observed adjusting refrigerator temperature. |
| ICRN | Infection Control Registered Nurse | Interviewed regarding antibiotic stewardship program. |
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