Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's designated representative of a significant change in the resident's condition following a fall.
Complaint Details
The complaint investigation found that the facility did not notify Resident #3's power of attorney (POA) immediately after the resident fell, notifying the POA only eight hours later when the resident was unresponsive and transferred to the hospital. The resident's representative expressed frustration and emotional distress over the delayed notification and lack of communication.
Findings
The facility failed to notify the designated representative for Resident #3 after the resident fell, resulting in delayed family notification until the resident became unresponsive and was transferred to the hospital. The resident subsequently died after being placed on hospice care.
Deficiencies (1)
Failure to notify the resident's representative of a significant change in the resident's condition after a fall.
Report Facts
Residents in sample: 4
Residents affected: 1
Time delay in notification: 8
BIMS score: 12
Resident age: Age of Resident #3 (redacted)
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 9, 2024
Visit Reason
The inspection was conducted in response to complaints regarding resident care, dignity, grievance handling, and failure to arrange timely medical specialist appointments for Resident #1.
Complaint Details
The investigation was complaint-driven based on grievances filed by Resident #1's representatives regarding catheter care, long call light wait times, and failure to arrange specialist appointments. The complaints were substantiated with findings of deficiencies.
Findings
The facility failed to maintain resident dignity by not emptying an external catheter canister timely, did not respond promptly to grievances about long call light wait times, and failed to arrange timely specialist medical appointments as ordered. These deficiencies affected one resident out of three reviewed and were associated with minimal harm or potential for harm.
Deficiencies (3)
Failed to ensure dignity was maintained for Resident #1 by emptying urine from her external catheter canister in a timely manner.
Failed to act promptly upon grievances concerning resident care and long call light wait times for Resident #1.
Failed to provide treatment and care according to orders by not arranging timely medical appointments with specialists for Resident #1.
Report Facts
Call light wait time: 48
BIMS score: 15
Date of survey completion: Sep 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding catheter care and stated nurses emptied and rinsed the canister every morning. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter care, grievance responses, and scheduling of specialist appointments. |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, safety, infection control, medication management, and emergency preparedness.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for oxygen therapy for several residents, inadequate pressure ulcer prevention and care, failure to investigate and prevent skin injuries of unknown origin, improper medication storage and security, lapses in infection prevention practices including hand hygiene and equipment disinfection, and failure to maintain emergency crash carts with current and functional equipment.
Deficiencies (6)
Failure to develop and implement a complete care plan including measurable objectives and timeframes for oxygen treatment and care for four residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, including delayed interventions and failure to update care plans.
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically failure to investigate skin discoloration and skin tear of unknown origin for one resident.
Failure to ensure medications were stored in locked compartments with controlled medications permanently affixed and medication carts locked when unattended.
Failure to maintain an infection prevention and control program including failure to provide residents opportunity for hand hygiene before meals, failure of staff to perform hand hygiene between tasks and in rooms with enhanced precautions, and failure to disinfect vital signs equipment between residents.
Failure to maintain emergency response carts with current, unexpired equipment and functional oxygen canisters.
Report Facts
Sample residents reviewed: 36
Residents affected: 4
Residents affected: 2
Residents affected: 1
Medication refrigerators: 3
Crash carts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care planning, pressure ulcer care, medication storage, infection control, and crash cart maintenance |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication refrigerator storage |
| Registered Nurse #2 | Registered Nurse | Observed leaving medication cart unlocked and interviewed |
| Registered Nurse #3 | Registered Nurse | Observed not sanitizing vitals machine between residents and interviewed |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding investigation of skin injuries |
| Director of Social Services | Director of Social Services | Interviewed regarding investigation of skin injuries |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding skin injury investigations |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices |
| Dietary Manager | Dietary Manager | Interviewed regarding hand hygiene practices during meal delivery |
| Regional Registered Dietitian | Regional Registered Dietitian | Interviewed regarding hand hygiene practices during meal delivery |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 28, 2022
Visit Reason
The inspection was conducted based on complaints regarding resident rights to participate in care planning, respect for personal belongings, timely reporting of suspected abuse or injury, and infection prevention related to oxygen equipment storage.
Complaint Details
The visit was complaint-related, investigating allegations that Resident #40 was not included in care planning and had personal belongings discarded, Resident #2 had an injury of unknown origin not reported timely, and Resident #9's oxygen equipment was improperly stored, risking infection.
Findings
The facility was found deficient in allowing Resident #40 to participate in care planning, respecting Resident #40's personal belongings, timely reporting of an injury of unknown origin for Resident #2, and maintaining sanitary storage of oxygen tubing and nasal cannula for Resident #9. Deficiencies were noted through observations, interviews, and record reviews.
Deficiencies (4)
Failed to provide Resident #40 the right to participate in the development and implementation of the resident's care plan.
Failed to ensure Resident #40 retained the right to have personal belongings treated with respect; personal items were discarded without consent.
Failed to timely report an injury of unknown origin for Resident #2 within the required timeframe.
Failed to ensure oxygen tubing and nasal cannula were stored in a sanitary manner when not in use for Resident #9.
Report Facts
Deficiencies cited: 4
Resident BIMS scores: 14
Resident BIMS scores: 3
Resident BIMS scores: 4
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Unit Manager | Unaware of bruising on Resident #2's arm and stated bruising should have been reported immediately. |
| Registered Nurse #3 | Documented Resident #2's skin assessment but failed to report bruising as injury of unknown origin. | |
| Director of Nursing | Director of Nursing | Reported injury to State, stated expectations for timely reporting of injuries and proper oxygen tubing storage. |
| Social Services Assistant #1 | Social Services Assistant | Provided information about Resident #40's care conference documentation and inventory sheet. |
| Social Services Director | Social Services Director | Described care conference invitation and documentation process. |
| Administrator | Administrator | Stated expectations for resident inclusion in care conferences and oxygen tubing storage. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Described proper infection control practices for oxygen tubing and nasal cannula storage. |
| Registered Nurse #2 | Registered Nurse | Described proper storage and replacement procedures for oxygen tubing and nasal cannula. |
Inspection Report
Routine
Deficiencies: 4
Date: Sep 26, 2019
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication regimen reviews, respiratory care, and psychotropic medication use in the facility.
Findings
The facility failed to ensure appropriate treatment and care for residents using orthotic devices, failed to provide necessary respiratory care orders for CPAP therapy, did not act timely on pharmacist medication recommendations, and failed to limit psychotropic medication use with appropriate stop dates or physician rationale. Several residents were affected by these deficiencies.
Deficiencies (4)
Failure to obtain physician orders for orthotic devices and include them in care plans, monitor skin condition, and provide ordered wound treatment for residents #19 and #296.
Failure to ensure treatment and care orders were in place for the use of CPAP therapy machine for residents #55 and #296.
Failure to act upon pharmacist recommendations timely for residents #84, #118, and #36 regarding medication diagnoses, doses, and frequency.
Failure to implement gradual dose reductions and limit PRN psychotropic medication orders to 14 days or provide physician rationale for extended use for residents #84, #60, #118, #36, and #9.
Report Facts
Residents reviewed: 43
Haldol gel administrations: 34
Clonazepam administrations: 23
Ativan administrations: 18
PRN Ativan administrations: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Unit Manager | Interviewed regarding CPAP therapy and monitoring for Resident #55 |
| DON | Director of Nursing | Interviewed regarding orthotic device orders, CPAP therapy, medication recommendations, and psychotropic medication use |
| LPN #1 | Unit Manager | Interviewed regarding pharmacy recommendations and psychotropic medication use for Residents #84, #118, and #60 |
| PSC | Pharmacy Services Consultant | Interviewed regarding pharmacist recommendations and medication regimen reviews |
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