Inspection Reports for
Hilltop Park Post Acute
290 S MONACO PRKY, DENVER, CO, 80224-
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted due to complaints regarding food quality and meal service issues at the facility, specifically related to resident grievances about cold food, meal ticket inaccuracies, and poor kitchen service.
Complaint Details
The complaint investigation found that the facility did not make prompt efforts to resolve food grievances, failed to fully investigate and document grievance resolutions, and did not take meaningful corrective actions. Resident interviews and record reviews revealed repeated issues with meal ticket inaccuracies and cold food, with seven grievances related to food and mealtimes from July to September 2025. The dietary manager and nursing staff acknowledged ongoing problems, and the director of nursing expressed disappointment in the facility's response to grievances.
Findings
The facility failed to ensure timely and effective responses to resident grievances concerning food quality and meal service. Multiple residents reported ongoing issues with cold food, inaccurate meal tickets, and poor communication from dietary staff, with inadequate investigation and corrective actions documented by the facility.
Deficiencies (1)
Failure to honor the resident's right to organize and participate in resident/family groups in the facility.
Report Facts
Grievances on record: 7
Grievance dates: 3
Grievance dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager (DM) | Named in findings related to meal ticket inaccuracies and food quality issues |
| Director of Nursing | Director of Nursing (DON) | Provided facility policy and expressed dissatisfaction with grievance resolution |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding assistance with grievance resolution system |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jul 29, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights, personal funds management, discharge and transfer procedures, pressure injury care, staff competencies, transportation assistance, and training programs at Hilltop Park Post Acute.
Complaint Details
The complaint investigation revealed multiple issues including resident rights violations, improper management of personal funds, inadequate discharge and transfer procedures, failure to prevent and treat pressure injuries, lack of nursing staff competency assessments, failure to provide necessary medical transportation, ineffective quality assurance program, and insufficient staff training.
Findings
The facility failed to ensure resident rights were respected, personal funds were properly managed, discharge and transfer processes were adequately documented and safe, pressure injuries were prevented and treated appropriately, nursing staff competencies were assessed and maintained, transportation needs were met, and staff received required training. Significant deficiencies included failure to provide timely pressure injury care resulting in a stage 4 pressure injury with osteomyelitis, failure to assist a resident with necessary gurney transportation, and incomplete discharge planning and summaries.
Deficiencies (8)
Failed to ensure resident rights were promoted and dignity maintained for seven residents.
Failed to provide quarterly personal funds statements and proper authorization for two residents.
Failed to ensure proper discharge and transfer procedures for multiple residents including documentation, notification, and safe discharge.
Failed to provide timely and necessary treatment and services to prevent and manage a facility-acquired stage 4 pressure injury with osteomyelitis for Resident #5.
Failed to ensure nursing staff competency in wound care and pressure injury management.
Failed to assist Resident #9 with scheduling medical transportation by gurney for follow-up appointments.
Failed to operate an effective quality assurance program to identify and address quality of care concerns, specifically pressure injuries.
Failed to develop, implement, and maintain an effective training program for all staff including required topics and annual in-service training.
Report Facts
Residents affected: 7
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant #1 | Regional Nurse Consultant | Provided facility policies and interviewed regarding deficiencies and training |
| Regional Nurse Consultant #2 | Regional Nurse Consultant | Provided support to DON and facility, interviewed regarding wound care and QAPI |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding facility operations, QAPI, and transportation issues |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care, staff competencies, and discharge planning |
| Wound Care Physician | Wound Care Physician | Provided wound care treatment and diagnosis for Resident #5 |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutritional care and deficiencies for Resident #5 and #2 |
| Transportation Coordinator | Transportation Coordinator | Interviewed regarding transportation arrangements for Resident #9 |
| Laundry Director | Laundry Director | Interviewed regarding management of air mattresses |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding air mattress use and settings |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding care and repositioning of Resident #5 |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted based on complaints alleging neglect related to the failure to provide necessary supplies such as adult briefs, wipes, linens, towels, and washcloths to residents.
Complaint Details
The complaint investigation found substantiated neglect due to inadequate provision of necessary supplies, confirmed by resident interviews, staff interviews, and direct observations.
Findings
The facility failed to ensure seven of 10 sampled residents were kept free from neglect by not providing essential supplies needed for their care, including adult briefs, wipes, linens, towels, and washcloths. Observations and interviews confirmed frequent shortages of these supplies, impacting residents' hygiene and well-being.
Deficiencies (1)
Failure to provide adult briefs, wipes, linens, towels, and washcloths to residents as required to maintain their highest practicable well-being.
Report Facts
Residents in sample: 46
Residents affected: 7
Storage rooms for supplies: 4
Supply room stocking time: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding frequent shortages of supplies and locked central supply storage room |
| CNA #2 | Certified Nurse Aide | Interviewed about running out of wipes and adult briefs and laundry delays |
| CNA #4 | Certified Nurse Aide | Interviewed about supply storage issues and delays in obtaining supplies |
| HKS | Housekeeping Supervisor | Interviewed about ordering and stocking supplies, storage rooms, and supply availability |
| DON | Director of Nursing | Interviewed regarding supply availability and staff concerns |
Inspection Report
Routine
Census: 46
Deficiencies: 8
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, respiratory care, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate supplies to residents, improper medication administration practices, delayed insulin administration, failure to assist with vision devices, inadequate feeding tube care, unsafe respiratory care practices creating immediate jeopardy, improper medication cart storage, and failure to follow infection control PPE protocols.
Deficiencies (8)
Failure to provide adult briefs, wipes, linens, towels and washcloths to residents as required to maintain their highest practicable well-being.
Failure to ensure nurses did not leave medications unattended at residents' bedsides.
Failure to administer insulin in a timely manner per physician orders.
Failure to assist residents with obtaining vision devices in a timely manner after optometry visit.
Failure to ensure feeding tube residents received tube feeding administrations as ordered.
Failure to provide safe and appropriate respiratory care for residents requiring specialized respiratory care, including lack of supplies, training, and care plans, resulting in immediate jeopardy.
Failure to ensure medication carts were cleaned with no loose medication and no food stored in medication carts.
Failure to establish and maintain an infection prevention and control program including failure to follow proper PPE procedures when entering residents' isolation rooms.
Report Facts
Residents in sample: 46
Residents affected by neglect deficiency: 7
Residents affected by medication administration deficiency: 2
Residents affected by insulin administration deficiency: 1
Residents affected by vision services deficiency: 1
Residents affected by feeding tube care deficiency: 1
Residents affected by respiratory care deficiency: 4
Medication carts with deficiencies: 4
Number of tablets loose in Heritage Way East medication cart: 27
Number of tablets loose in Heritage Way medication cart: 8
Number of tablets loose in Grand Heritage medication cart #1: 54.5
Number of tablets loose in Grand Heritage medication cart #2: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency for leaving medications unattended |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, respiratory care, and infection control deficiencies |
| Respiratory Care Director | Respiratory Care Director | Involved in respiratory care deficiencies and training |
| Certified Respiratory Therapist | Certified Respiratory Therapist | Interviewed regarding respiratory care and training |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in respiratory care and medication cart deficiencies |
| LPN #1 | Licensed Practical Nurse | Involved in respiratory nebulizer treatment deficiency |
| LPN #4 | Licensed Practical Nurse | Observed with loose medications in medication cart |
| LPN #2 | Licensed Practical Nurse | Observed with loose medications and food in medication cart |
| LPN #9 | Licensed Practical Nurse | Observed performing trach care improperly |
| Certified Nurse Aide #2 | Certified Nurse Aide | Observed failing to use proper PPE in isolation room |
Inspection Report
Deficiencies: 1
Date: Oct 25, 2023
Visit Reason
The inspection was conducted to evaluate compliance with PASARR screening requirements for mental disorders or intellectual disabilities, specifically regarding the failure to conduct a preadmission screening resident review for a resident who remained in the facility beyond the provisional admission approval period.
Findings
The facility failed to submit a new PASRR Level I screening for Resident #3 after the 30-day provisional admission period expired. Interviews and record reviews confirmed that the facility did not comply with the PASRR screening requirements for this resident.
Deficiencies (1)
Failure to conduct a preadmission screening resident review (PASRR) for Resident #3 who remained in the facility beyond the 30-day provisional admission approval.
Report Facts
Residents reviewed for PASRR: 10
Residents affected: 1
Provisional admission period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Interviewed regarding PASRR screening process and failure to submit new Level I PASRR | |
| PASRR Program Administrator | Interviewed confirming facility responsibility to submit new Level I PASRR |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with policies and procedures related to pneumococcal immunizations for residents, as part of the annual survey process.
Findings
The facility failed to implement proper policies and procedures regarding pneumococcal vaccinations for six of eight residents reviewed. Specific failures included not offering the vaccine upon admission, not offering additional doses, and lacking signed consent for refusals. The facility's documentation and use of the Colorado Immunization Information System (CIIS) were inconsistent.
Deficiencies (3)
Failed to offer Resident #1 and #8 the pneumococcal vaccine upon admission
Failed to offer additional doses of the pneumococcal vaccine to Resident #2, #3, and #5
Failed to have a signed consent of refusal for Resident #6
Report Facts
Residents reviewed for immunizations: 8
Residents with immunization deficiencies: 6
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide timely copies of medical records for certain residents and failure to ensure residents were assessed by a registered nurse following falls.
Complaint Details
The complaint investigation found that medical records for Residents #1 and #6 were not provided timely despite multiple requests. Additionally, the facility failed to ensure RN assessments were completed and documented following falls for Residents #1, #2, and #3.
Findings
The facility failed to provide requested medical records timely for Residents #1 and #6, and failed to ensure that Residents #1, #2, and #3 were assessed by a registered nurse following falls, with documentation missing for RN assessments prior to residents being moved after falls.
Deficiencies (2)
Failure to provide copies of medical records timely for Residents #1 and #6.
Failure to ensure Residents #1, #2, and #3 were assessed by a registered nurse following falls, with no RN assessment documented prior to moving residents.
Report Facts
Residents sampled: 7
Residents affected by medical records deficiency: 2
Residents affected by RN assessment deficiency: 3
Time delay for medical records provision: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered nurse #1 | Registered Nurse | Interviewed regarding RN assessment requirements following resident falls |
| Director of Nursing | Interviewed regarding RN assessment requirements and medical records delay | |
| Nursing Home Administrator | Interviewed regarding medical records delay and facility policies | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Involved in resident fall assessments but lacked RN assessment documentation |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Found Resident #2 on floor after fall |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Found Resident #2 on floor after fall |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 15, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to provide advance beneficiary notifications (ABNs) for Medicare Part A services, failure to complete timely PASARR screenings, failure to develop appropriate care plans for wounds, failure to provide regular baths/showers for dependent residents, and failure to ensure influenza vaccinations were administered as requested.
Complaint Details
The complaint investigation focused on failure to provide advance beneficiary notifications for Medicare Part A service terminations, failure to complete PASARR screenings timely, failure to develop appropriate care plans for wounds, failure to provide regular bathing and hygiene care, and failure to administer influenza vaccinations as requested.
Findings
The facility failed to provide timely ABNs and Notices of Medicare Non-Coverage (NOMNC) to residents discharged from Medicare Part A services, failed to complete level I PASARR screenings prior to admission for some residents, failed to develop a care plan for a resident's vascular wound, failed to provide regular bathing and hygiene care to a dependent resident, and failed to ensure influenza vaccination was administered to a resident who requested it.
Deficiencies (5)
Failed to ensure residents were informed in advance and in writing of items and services not covered under Medicaid and of the right to an expedited review of service termination for 3 residents.
Failed to ensure level I PASARR screenings were completed prior to admission for 2 residents.
Failed to develop a care plan to address the need for wound care and related monitoring for 1 resident.
Failed to ensure baths/showers were regularly provided to maintain good hygiene for 1 dependent resident.
Failed to ensure influenza vaccination was given to 1 resident who requested it.
Report Facts
Residents reviewed for advance beneficiary notification: 3
Residents reviewed for PASARR: 3
Residents reviewed for wounds: 3
Residents reviewed for activities of daily living: 3
Residents reviewed for vaccinations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Social Worker (SW) | Responsible for issuing ABNs to residents coming off Medicare Part A services; mentioned in ABN deficiency findings |
| Business Office Manager | Business Office Manager (BOM) | Responsible for generating ABNs; mentioned in ABN deficiency findings |
| Administrator | Administrator | Provided education on ABN responsibilities and expected compliance; mentioned in multiple interviews |
| Director of Nursing | Director of Nursing (DON) | Provided expectations on timely issuance of ABNs and NOMNCs, care planning, bathing, and vaccination administration |
| MDS Coordinator | MDS Coordinator | Responsible for care plans; acknowledged missing wound care plan for Resident #156 |
| Certified Nurse Assistant | Certified Nurse Assistant (CNA) #1 | Described bathing procedures and documentation |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) #2 | Described shower scheduling and refusal documentation |
| Infection Preventionist | Infection Preventionist | Confirmed Resident #52 had not received influenza vaccination until 12/14/2022 |
| Registered Nurse | Registered Nurse (RN) #3 | Described vaccination process |
| Registered Nurse | Registered Nurse (RN) #4 | Described vaccination consent and administration process |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 26, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare regulations, including resident care, infection control, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to complete PASRR Level II screening prior to admission, inadequate treatment and services for activities of daily living, failure to prevent worsening of stage four pressure ulcers, inadequate supervision and fall prevention, failure to provide appropriate pain management, failure to collaborate effectively with hospice providers, and lapses in infection prevention and control practices.
Deficiencies (7)
Failed to provide preadmission screening and resident review (PASRR) Level II for residents diagnosed with mental illness prior to admission.
Failed to follow physician's orders for resident to wear Geri sleeves to protect sensitive skin, resulting in skin tears.
Failed to prevent worsening of stage four pressure ulcers for two residents due to inconsistent wound care and failure to follow physician orders.
Failed to provide adequate supervision and environment free from accident hazards, including failure to update care plan and assess resident after falls.
Failed to provide safe, appropriate pain management for residents with severe pain during wound care, including failure to premedicate and notify physician of ineffective pain medication.
Failed to collaborate with hospice provider to develop coordinated plan of care and ensure adequate communication and documentation.
Failed to ensure proper infection control practices including offering hand hygiene to residents before meals, wearing appropriate PPE in isolation rooms, and wiping down face shields between residents.
Report Facts
Residents reviewed: 29
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding failure to ensure Geri sleeves were worn and pain management |
| ADON | Assistant Director of Nursing | Interviewed regarding wound care, pain management, hospice collaboration, and infection control |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding wound care and pain management |
| CNA #3 | Certified Nurse Aide | Observed and interviewed regarding infection control lapses |
| LPN #4 | Licensed Practical Nurse | Observed entering isolation room without proper PPE |
| CNA #4 | Certified Nurse Aide | Observed and interviewed regarding improper PPE use in isolation room |
| Wound Doctor | Interviewed regarding wound care deficiencies and pain management | |
| NHA | Nursing Home Administrator | Interviewed regarding hospice documentation and infection control |
| HRN | Hospice Registered Nurse | Interviewed regarding hospice communication and documentation |
Viewing
Loading inspection reports...
