Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 10
Date: Jul 16, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignity and engagement, inadequate investigation of abuse allegations, insufficient assistance with activities of daily living, lack of meaningful activities, improper use and monitoring of braces and splints, unsafe use of bed rails without proper assessment and consent, medication administration errors, inadequate hydration provision, improper food handling and sanitation practices, and failure to maintain an effective infection prevention and control program.
Deficiencies (10)
Failure to honor residents' rights to a dignified existence and promote quality of life through meaningful staff interaction.
Failure to thoroughly investigate allegations of abuse and resident-to-resident altercations.
Failure to provide appropriate care and assistance with activities of daily living, including safe transfers, communication, incontinence care, and repositioning.
Failure to provide meaningful activities and communication support in residents' native language.
Failure to ensure appropriate use, monitoring, and physician orders for braces and splints to maintain range of motion and prevent contractures.
Failure to assess residents for bed rail use, obtain informed consent, and ensure safe installation and maintenance.
Failure to ensure residents were free from significant medication errors, including failure to administer prescribed seizure medication and notify physician.
Failure to provide sufficient hydration consistent with resident needs and preferences.
Failure to procure, store, prepare, distribute, and serve food in accordance with professional standards, including improper hand hygiene and cross contamination during meal service.
Failure to provide and implement an effective infection prevention and control program, including inadequate cleaning of resident rooms, improper hand hygiene by housekeeping staff, improper linen and clothing transport, and failure to use appropriate PPE for residents on enhanced barrier precautions.
Report Facts
Residents sampled: 27
Observation period: 6
BIMS score: 3
BIMS score: 5
BIMS score: 6
BIMS score: 9
BIMS score: 4
BIMS score: 2
Medication dose: 5
Hydration volume: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings related to lack of interaction with residents, improper transfer techniques, and hydration assistance |
| LPN #3 | Licensed Practical Nurse | Named in findings related to abuse investigation, medication administration, brace monitoring, and infection control |
| Activity Director | Activity Director | Named in findings related to resident activities and communication support |
| Director of Rehabilitation | Director of Rehabilitation | Named in findings related to brace use and resident mobility |
| Housekeeper #1 | Housekeeper | Named in findings related to improper cleaning and hand hygiene |
| Laundry Aide | Laundry Aide | Named in findings related to improper linen transport and handling |
| Dietary Supervisor | Dietary Supervisor | Named in findings related to food handling and sanitation |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards following observations, record reviews, and interviews related to resident care and safety, including treatment of bruises and fall prevention.
Findings
The facility failed to ensure timely assessment, investigation, and notification regarding a resident's bruise, and failed to implement effective person-centered fall prevention interventions for two residents at high fall risk, resulting in multiple falls and injuries.
Deficiencies (2)
Failed to timely assess, investigate, notify physician, and implement interventions for a resident's bruise of unknown origin.
Failed to develop and implement person-centered care plans with effective interventions to reduce falls for two residents at high fall risk.
Report Facts
Bruise measurement: 8.5
Bruise measurement: 11
Fall risk score: 17
Fall risk score: 18
Fall incidents: 5
Fall incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified nurse aide #2 | Certified Nurse Aide | Interviewed regarding responsibility to notify nurse of resident condition changes |
| Licensed practical nurse #2 | Licensed Practical Nurse | Interviewed about responsibilities to complete assessments and report changes |
| Registered nurse #1 | Registered Nurse | Interviewed about assessment and notification duties for resident bruising |
| Director of Nursing | Director of Nursing | Interviewed about nurse responsibilities for change of condition assessments and notifications |
| Certified nurse aide #1 | Certified Nurse Aide | Interviewed about knowledge of fall risk interventions and documentation practices |
| Licensed practical nurse #1 | Licensed Practical Nurse | Interviewed about fall risk identification and intervention documentation |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about fall risk care plans, frequency of checks, and person-centered interventions |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 19, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and assistance to prevent falls, specifically concerning Resident #2 who experienced an avoidable fall with minor injury.
Complaint Details
The complaint investigation focused on Resident #2 who fell from bed on 11/30/19 resulting in a forehead laceration and hematoma. The fall occurred when a CNA left the room to get a Hoyer lift, leaving the resident unattended. The facility's post-fall investigation and interdisciplinary team review confirmed the fall and identified failures in supervision and staff training. Resident was on hospice care and had severe cognitive impairment.
Findings
The facility failed to ensure Resident #2 received adequate supervision during transfers, resulting in a fall with minor injury including a forehead laceration and hematoma. The facility also failed to provide two staff during mechanical lifts and adequate staff training post-fall to ensure safe transfers according to the care plan and policy.
Deficiencies (3)
Failed to ensure Resident #2 received adequate supervision to prevent an avoidable fall with minor injury.
Failed to provide two staff during the resident's transfer from bed to wheelchair.
Failed to provide adequate staff training after the resident's fall to ensure safe transfers according to care plan and policy.
Report Facts
Residents reviewed for falls: 23
Resident #2 Fall Risk Review total score: 9
Hematoma size: 1.9
Hematoma size: 0.5
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