Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 3
Date: Sep 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on compliance with infection control policies and procedures related to COVID-19 precautions.
Findings
The facility failed to maintain an effective infection prevention and control program on two of eight units, including failure to disinfect vital signs machines after use in COVID-19 positive rooms and between residents, and failure of housekeeping staff to properly doff PPE and seal trash bags inside COVID-19 positive rooms.
Deficiencies (3)
Failed to ensure the vital signs machine was disinfected after being used in a COVID-19 positive room.
Failed to disinfect the vital signs machine after each resident's use on the secure unit.
Failed to ensure housekeeping staff doffed their PPE and closed the trash bags before exiting a COVID-19 positive room.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in observations and interview related to failure to disinfect vital signs machine after use in COVID-19 positive room. |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control practices and deficiencies. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed together with Infection Preventionist about infection control deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 19, 2025
Visit Reason
The inspection was conducted due to complaints from residents regarding long call light response times and unresolved grievances related to this issue.
Complaint Details
The complaint investigation involved three residents (#13, #11, and #12) who reported long call light wait times ranging from 40 minutes to one and a half hours. Residents reported incidents of soiling themselves while waiting and staff turning off call lights without returning. The grievance reports lacked documentation on resident satisfaction or appeal processes. Staff interviews acknowledged the issues and agreed call lights should remain on until needs are addressed.
Findings
The facility failed to promptly resolve grievances for three residents who reported long call light wait times, resulting in negative impacts such as residents soiling themselves and feeling degraded. Staff interviews confirmed occasional long wait times and improper call light handling.
Deficiencies (1)
Failure to ensure residents' grievances regarding long call light times were resolved promptly.
Report Facts
Call light wait time: 100
Call light wait time: 90
Call light wait time: 40
BIMS score: 14
BIMS score: 15
BIMS score: 15
Inspection Report
Routine
Deficiencies: 4
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, including hand hygiene practices during medication pass and meal service, and to assess the facility's water management plan for controlling Legionella and other waterborne pathogens.
Findings
The facility failed to maintain proper infection prevention and control practices, including inadequate hand hygiene during medication administration and meal service, improper handling of resident drink glasses and silverware, and failure to sanitize meal trays between uses. Additionally, the facility was unable to provide documentation of monitoring or control measures for Legionella as required by their Water Management Plan.
Deficiencies (4)
Failure to follow infection control practices during medication pass, including not sanitizing hands between residents.
Failure to demonstrate proper hand hygiene while assisting residents with meals, including touching mouthpieces of drink glasses and not sanitizing hands.
Failure to ensure control measures for monitoring and preventing Legionella and waterborne pathogens growth were included and documented in the facility's water management plan.
Failure to pass medications in a sanitary manner.
Report Facts
Observation dates: 3
Water Management Plan date: 2023
Maximum days a room can be vacant without action: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Observed failing to sanitize hands during medication pass | |
| CNA #2 | Observed failing to perform hand hygiene during meal service and handling resident drink glasses improperly | |
| Assistant Director of Nursing (ADON) | Interviewed multiple times regarding infection control practices and provided education to staff | |
| Infection Preventionist (IP) | Interviewed regarding dining room cup handling observations | |
| Nursing Home Administrator (NHA) | Interviewed regarding housekeeping and water management monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The inspection was conducted following a complaint investigation into a fall incident involving Resident #1 who fell from a ceiling lift on 5/27/2023, resulting in serious injuries and death.
Complaint Details
The investigation was complaint-driven due to a fall incident on 5/27/2023 involving Resident #1. The fall was substantiated as an accident caused by human error and equipment malfunction. The nurse aide transferred the resident alone despite the care plan requiring two-person assistance, and the ceiling lift remote was malfunctioning. The resident sustained multiple fractures and a subdural hematoma and died on 5/28/2023.
Findings
The facility failed to ensure adequate supervision and safe use of mechanical lifts, resulting in Resident #1 falling from a ceiling lift due to improper transfer by a single nurse aide without assistance, malfunctioning lift equipment, and failure to follow facility policies. The resident sustained multiple fractures and a subdural hematoma and later died. The facility identified equipment malfunctions, policy noncompliance, and human error as causes and implemented corrective actions including staff education, equipment audits, and policy changes requiring two-person assistance for all lifts.
Deficiencies (1)
Failure to ensure adequate supervision and safe transfer using mechanical lifts, resulting in a resident fall with serious injury and death.
Report Facts
Residents affected: 1
Date of fall incident: May 27, 2023
Date of death: May 28, 2023
Number of lifts removed or tagged out: 56
Number of lifts functioning properly: 46
Number of lifts not working but still in rooms: 15
Number of lifts in tub rooms working properly: 4
Number of residents requiring mechanical lifts: 26
Number of residents using Hoyer lifts: 7
Number of random audits completed: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Transferred Resident #1 alone despite two-person transfer requirement; suspended and terminated for policy violations |
| RN #1 | Registered Nurse | Responded to fall incident, provided initial assessment and care |
| RN #2 | Charge Nurse | Responded to fall, stabilized resident, notified family, involved in investigation |
| RN #3 | Registered Nurse | Responded to fall, monitored vital signs, assisted in resident care |
| CNA #1 | Certified Nurse Aide | Witnessed fall incident, involved in transfer observations and interviews |
| CNA #3 | Certified Nurse Aide | Involved in transfer observations and interviews |
| NHA | Nursing Home Administrator | Provided investigation documentation and interviews |
| SDC | Staff Development Coordinator | Conducted investigation, provided staff education and training on lift safety |
| RMD | Regional Maintenance Director | Conducted ceiling lift audits and maintenance assessments |
| MS | Maintenance Supervisor | Responsible for maintenance requests and lift assessments |
| DON | Director of Nursing | Oversaw nursing staff training and policy changes |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 19, 2022
Visit Reason
The inspection was conducted following a complaint related to a resident eloping from the secure unit unsupervised, medication cart security, and infection control practices during wound care.
Complaint Details
The complaint investigation was substantiated by observations, interviews, and record reviews confirming the resident eloped unsupervised, medication cart security lapses, and infection control deficiencies during wound care.
Findings
The facility failed to prevent a cognitively impaired resident from exiting the secure unit unsupervised, left a medication cart unlocked and unattended, and failed to maintain proper infection control practices during wound care, including improper glove use and failure to clean equipment between wounds.
Deficiencies (3)
Failed to prevent a resident with wandering behaviors from exiting the facility unsupervised.
One of four medication carts was left unlocked and unattended.
Failed to maintain infection control practices during wound care, including not cleaning hands or changing gloves between wounds and not cleaning scissors between uses.
Report Facts
Residents affected: 1
Medication carts: 4
Medication cart unlocked: 1
Wounds: 7
Time outside unsupervised: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Observed Resident #36 outside and redirected them back into the facility |
| RN #6 | Registered Nurse | Left medication cart unlocked and unattended |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding elopement incident, medication cart policy, and infection control expectations |
| Wound Care Nurse | Wound Care Nurse (WCN) | Observed failing to follow infection control practices during wound care |
| Infection Control Preventionist | Infection Control Preventionist (ICP) | Provided expectations for infection control practices during wound care |
| Administrator | Administrator | Provided statements on supervision expectations and infection control standards |
| Maintenance Director | Maintenance Director (MD) | Assessed secure unit doors after elopement incident |
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