Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
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: 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
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
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 |
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