Inspection Reports for
Riverdale Post Acute
2311 E BRIDGE ST, BRIGHTON, CO, 80601-2547
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
33% occupied
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 2
Date: Jan 22, 2026
Visit Reason
The inspection was conducted to assess compliance with medication storage and infection prevention and control standards at the nursing facility.
Findings
The facility failed to ensure medications were properly stored and secured, with medication carts left unlocked and unattended. Additionally, improper infection control practices were observed during wound care, including failure to perform hand hygiene and sanitize equipment.
Deficiencies (2)
F 0761: The facility failed to ensure medication and treatment carts were kept locked when not monitored, and medications were improperly stored and prepoured, left unattended on medication carts.
F 0880: The facility failed to maintain an infection control program, with licensed practical nurse observed not performing hand hygiene or sanitizing equipment during wound care for a resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication storage deficiency for leaving medication cart unattended. |
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency for improper wound care practices. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication and treatment cart locking procedures. |
| Director of Nursing | Director of Nursing | Interviewed and provided education on medication storage and infection control. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 1, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident physical abuse incidents within the facility.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident physical abuse, including altercations involving residents #16, #17, #19, #8, #4, #18, and #11. The facility failed to report two incidents involving residents #6 and #17 to the State Survey Agency as required.
Findings
The facility failed to ensure residents were kept free from physical abuse by other residents, with multiple incidents involving several residents. The facility also failed to timely report alleged physical abuse incidents to the State Survey Agency as required by law.
Deficiencies (2)
F0600: The facility failed to protect residents from physical abuse by other residents, with multiple documented incidents involving residents #16, #17, #19, #8, #4, #18, and #11 between 6/7/25 and 9/17/25.
F0609: The facility failed to timely report alleged physical abuse incidents involving residents #6 and #17 to the State Survey Agency as required by state law.
Report Facts
Residents reviewed for abuse: 18
Residents with abuse incidents: 7
Date of survey completion: Dec 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident behaviors and care plan updates related to Resident #17 and others |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Interviewed regarding Resident #17's behaviors and care plan updates |
| NHA | Nursing Home Administrator | Provided facility policies, investigations, and interview regarding abuse reporting and care plan updates |
| DON | Director of Nursing | Interviewed regarding abuse investigations, care plan updates, and resident monitoring |
| SSD | Social Services Director | Interviewed regarding abuse investigations and resident care interventions |
Inspection Report
Routine
Deficiencies: 17
Date: Mar 26, 2025
Visit Reason
Routine inspection of Riverdale Post Acute nursing home to assess compliance with regulatory requirements including resident care, safety, infection control, medication management, and facility environment.
Findings
The facility had multiple deficiencies including failure to provide residents with prescribed diets and appropriate beverage cups, failure to maintain resident privacy, failure to protect residents from abuse, failure to develop comprehensive care plans, failure to document resuscitation choices, medication errors, failure to maintain safe environment and infection control, and failure to properly manage hospice care and arbitration agreements.
Deficiencies (17)
F 0550: Failed to provide residents on the Aspen unit with non-disposable beverage cups at meals and failed to ensure residents prescribed puree diets received menu options as ordered or preferred.
F 0575: Failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups in a readable font and accessible location for residents.
F 0583: Failed to keep resident medical records private and confidential by allowing resident meal tickets to be accessible to guests.
F 0600: Failed to protect residents from abuse including sexual abuse by Resident #62 and physical abuse among residents #97, #34, #42, and #58; and failed to report alleged sexual abuse to the State Survey Agency.
F 0656: Failed to develop comprehensive care plans for residents #1, #75, and #249 addressing supplemental oxygen, PICC line care, and insomnia.
F 0678: Failed to document resuscitation choices accurately for Resident #50 including failure to document refusal to complete MOST form or discussion of resuscitation choices.
F 0684: Failed to provide routine maintenance and care for Resident #1's PICC line including lack of physician orders for dressing changes and lack of documentation of dressing changes.
F 0689: Failed to ensure Resident #97 received timely and effective fall prevention interventions including consistent use of protective helmets and failed to ensure residents #37 and #47 were transferred according to care plans.
F 0692: Failed to weigh Resident #50 upon admission and monitor nutritional status despite potential nutrition problems.
F 0693: Failed to ensure Resident #96 was assessed and monitored for safety while self-administering feeding tube feedings and lacked physician orders and care plan documentation for self-administration.
F 0812: Nourishment refrigerators were not maintained at safe temperatures, health shakes were unlabeled, and the kitchen floor, walls, and ice machine were not maintained in a clean and sanitary condition.
F 0921: Failed to maintain a safe, functional, sanitary and comfortable environment including damaged furniture, rotted door frames, water damaged ceilings and walls, unsanitary bathrooms, missing curtains, broken heating vents, and holes in walls in resident rooms.
F 0880: Failed to implement an infection prevention and control program including failure to follow enhanced barrier precautions for Resident #1 with a PICC line and failure to maintain proper cleaning and sanitizing techniques in resident rooms.
F 0847: Failed to thoroughly explain the binding arbitration agreement to residents #54, #85, and #96 and/or their representatives and failed to document their understanding; and failed to include required components in the arbitration agreement such as neutral arbitrator selection and venue convenience.
F 0759: Medication administration error rate was 6.06% with errors including underdosing omeprazole and misplacement of lidocaine patch.
F 0805: Failed to ensure residents received food prepared according to prescribed mechanically altered diets; puree diets were not prepared correctly and included inappropriate food items increasing choking risk.
F 0758: Failed to ensure residents #95, #75, and #249 were free from unnecessary psychotropic medications including lack of consents and behavior monitoring.
Report Facts
Medication administration errors: 2
Fall incidents: 5
Temperature readings: 42
Temperature readings: 48
Weight: 186
Protein needs: 102
Tube feeding volume: 501
Medication doses: 40
Medication doses: 20
Medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Administered incorrect medication dose and applied lidocaine patch incorrectly |
| RA #1 | Restorative Aide | Failed to wear PPE when assisting Resident #1 with PICC line |
| CNA #2 | Certified Nurse Aide | Unaware of EBP for Resident #1 |
| LPN #1 | Licensed Practical Nurse | Interviewed about PICC line care and psychotropic medication monitoring |
| DON | Director of Nursing | Interviewed about abuse reporting, PICC line care, fall prevention, medication consent, and infection control |
| NHA | Nursing Home Administrator | Interviewed about arbitration agreements, kitchen sanitation, and facility maintenance |
| HK | Housekeeper | Observed failing to follow proper cleaning and sanitizing techniques |
| MDSC | MDS Coordinator | Interviewed about care plans and transfer needs |
| DD | Dietary Director | Interviewed about diet preparation and nourishment refrigerator temperatures |
| CNA #3 | Certified Nurse Aide | Interviewed about transfer and weighing Resident #50 |
| LPN #4 | Licensed Practical Nurse | Interviewed about Resident #97 fall and helmet use |
| CNA #8 | Certified Nurse Aide | Interviewed about Resident #97 fall and helmet use |
| CNA #5 | Certified Nurse Aide | Interviewed about Resident #47 transfer |
| MDSC | MDS Coordinator | Interviewed about Resident #47 transfer and falls |
| LPN #2 | Licensed Practical Nurse | Interviewed about psychotropic medication monitoring |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Interviewed about Resident #62 behaviors and medication monitoring |
| LPN #5 | Licensed Practical Nurse | Interviewed about psychotropic medication monitoring |
| HKS | Housekeeping Supervisor | Interviewed about cleaning procedures and supplies |
| MTD | Maintenance Director | Interviewed about facility maintenance issues |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 26, 2025
Visit Reason
The inspection was conducted based on complaints and allegations related to resident care, abuse, diet preparation, fall prevention, and facility sanitation.
Complaint Details
The complaint investigation included allegations of failure to provide proper diet textures, failure to protect residents from abuse including sexual and physical abuse, failure to report abuse to the State Agency, failure to prevent falls and injuries, failure to use mechanical lifts for transfers, and failure to maintain sanitary food preparation and storage areas.
Findings
The facility failed to provide residents with diets prepared according to their prescribed texture, failed to protect residents from abuse including sexual and physical abuse, failed to report an incident of potential sexual abuse to the State Agency, failed to implement timely fall prevention interventions resulting in multiple falls with injury, failed to ensure proper transfer techniques for residents requiring mechanical lifts, and failed to maintain sanitary conditions in the kitchen and nourishment refrigerators.
Deficiencies (6)
F 0550: The facility failed to provide residents on the Aspen unit with non-disposable beverage cups at meals and failed to ensure residents prescribed puree diets received menu options as ordered.
F 0600: The facility failed to protect four residents from sexual and physical abuse by other residents and failed to report an allegation of abuse to the State Agency.
F 0609: The facility failed to timely report an incident of potential sexual abuse involving Resident #62 to the State Survey Agency.
F 0689: The facility failed to ensure three residents remained free from accident hazards by not implementing timely fall prevention interventions and failing to use mechanical lifts as required for transfers.
F 0805: The facility failed to ensure residents received food prepared according to their prescribed diet texture and served puree vegetables that were not appropriate, risking choking hazards.
F 0812: The facility failed to maintain nourishment refrigerators at safe temperatures, failed to label health shakes with thaw dates, and failed to maintain a clean and sanitary kitchen environment including unclean ice machine filters and missing floor tiles.
Report Facts
Residents reviewed for abuse: 9
Residents reviewed for accident hazards: 8
Sample residents: 36
Fall incidents for Resident #97: 5
Temperature readings above safe limit: 9
Missing coving tiles: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Witnessed Resident #62 masturbating in another resident's room. |
| LPN #4 | Licensed Practical Nurse | Reported Resident #97's fall and helmet issues. |
| CK #1 | Cook | Prepared meals that did not meet prescribed diet textures. |
| DD | Dietary Director | Provided menu extensions and noted diet texture errors. |
| NHA | Nursing Home Administrator | Interviewed regarding abuse reporting and kitchen sanitation. |
| DON | Director of Nursing | Interviewed regarding abuse incidents, fall prevention, and kitchen sanitation. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Jan 14, 2025
Visit Reason
The inspection was conducted due to concerns about the malfunctioning alarm system on the secured unit's exit door, which posed a safety risk for residents potentially exiting unsupervised.
Complaint Details
The investigation was complaint-related, triggered by concerns about the alarm system failure on the secured unit exit door. The complaint was substantiated as the alarm was confirmed broken and residents were able to exit unsupervised.
Findings
The facility failed to ensure the alarm on the secured unit's exit door was functioning properly, allowing residents to exit without alerting staff. Staff interviews and observations confirmed the alarm had been broken for weeks, and corrective actions were initiated during the survey.
Deficiencies (1)
F 0689: The facility failed to ensure the alarm on the door to the outside secured patio was functioning properly, allowing residents to exit without staff notification. The door alarm was broken and did not audibly alert staff when opened, posing a potential hazard.
Report Facts
Residents on secured unit: 35
Residents attempting to exit: 3
Smoking breaks per day: 7
Staff assigned to monitor door: 1
Alarm repair completion date: Jan 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding alarm failure and corrective action plan |
| Director of Nursing | DON | Interviewed about alarm failure and supervision on secured unit |
| Corporate Consultant Nurse | CCN | Demonstrated door repair and interviewed about alarm issues |
| Environmental Service Director | ESD | Part of team that repaired door alarm and responsible for maintenance |
| Certified Nurse Aide #1 | CNA | Reported alarm failure and lack of training on door system |
| Certified Nurse Aide #2 | CNA | Observed door opening without alarm and described monitoring challenges |
| Certified Nurse Aide #3 | CNA | Reported alarm system not working for several weeks and lack of maintenance |
| Certified Nurse Aide #4 | CNA | Assigned to monitor door and reported residents found unattended outside |
| Certified Nurse Aide #5 | CNA | Reported alarm never sounded during seven months working on memory care unit |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's pest control program and ensure the environment was free of pests such as flies, mice, and insects.
Findings
The facility failed to provide an effective pest control program, resulting in a persistent fly infestation in the kitchen and dining room areas. Despite multiple interventions, flies were observed landing on residents and food preparation surfaces, posing a potential health risk.
Deficiencies (1)
F 0925: The facility failed to maintain an effective pest control program to prevent and manage a fly infestation in the kitchen and dining room. Flies were observed landing on residents and food surfaces, and the back kitchen door was left open without screens, allowing flies to enter.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to investigate complaints of resident-to-resident abuse incidents involving multiple residents in the secure unit of the facility.
Complaint Details
The complaint investigation focused on resident-to-resident abuse incidents involving Resident #39 and other residents (#71, #10, #43). The facility documented the abuse as unsubstantiated despite witness accounts, video review, and hospital documentation of injury. The investigation found failures in abuse prevention and response protocols.
Findings
The facility failed to ensure freedom from resident-to-resident abuse for three residents, with multiple witnessed incidents involving Resident #39 as the assailant. The facility unsubstantiated the abuse despite evidence including witness statements and hospital reports. Additional findings included failure to conduct annual CNA performance reviews and provide required training, and failure to ensure food was palatable, attractive, and served at a safe temperature.
Deficiencies (3)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse by other residents. Multiple incidents involving Resident #39 assaulting Residents #71, #10, and #43 were witnessed but not substantiated by the facility despite evidence of injury and aggression.
F 0730: The facility failed to conduct yearly certified nurse aide performance reviews and provide 12 hours of in-service training based on these reviews for five CNAs hired prior to July 2022.
F 0804: The facility failed to ensure food was palatable, attractive, served at a safe and appetizing temperature, and provided with condiments. Observations and resident interviews reported cold, overcooked, bland food and missing condiments.
Report Facts
Residents reviewed: 35
Certified Nurse Aides reviewed: 5
Temperature of omelet: 112
Temperature of hash browns: 104
Temperature of toast: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSD #2 | Social Services Director | Interviewed regarding resident behaviors and abuse incidents |
| NHA | Nursing Home Administrator | Provided facility policies, investigation summaries, and follow-up documentation |
| DON | Director of Nursing | Interviewed about staff training and management of aggressive resident behaviors |
| CNA #3 | Certified Nurse Aide | Interviewed about resident altercations and care plan accessibility |
| Dietary Supervisor | Dietary Supervisor | Interviewed about food service issues and kitchen observations |
Inspection Report
Routine
Census: 93
Deficiencies: 9
Date: Jul 27, 2023
Visit Reason
Routine inspection of Riverdale Post Acute nursing home to assess compliance with regulatory requirements including resident rights, abuse prevention, foot care, CNA training, dementia care, dental services, food quality, and pest control.
Findings
The facility failed to ensure timely call light response, freedom from resident-to-resident abuse, proper foot care, annual CNA performance reviews, adequate dementia care, timely dental services, palatable and safe food service, honoring resident food preferences, and effective pest control. Multiple residents reported long call light wait times and resident-to-resident abuse incidents involving Resident #39 were not substantiated appropriately. Food was often cold, unpalatable, and missing condiments. Flies were pervasive throughout the facility including dining and kitchen areas.
Deficiencies (9)
F0550: Facility failed to ensure residents' right to dignified existence by not answering call lights timely, with response times up to two hours and 55 minutes.
F0600: Facility failed to protect residents from resident-to-resident abuse involving Resident #39, with multiple physical and verbal abuse incidents unsubstantiated despite evidence.
F0687: Facility failed to ensure Resident #81 received timely podiatry care; multiple missed podiatry visits were documented without resident refusal.
F0730: Facility failed to conduct annual CNA performance reviews and provide 12 hours of in-service training for five CNAs hired prior to July 2022.
F0744: Facility failed to provide appropriate dementia care for Residents #39, #10, and #71 including lack of engagement activities, failure to update care plans after abuse incidents, and insufficient interventions to prevent further abuse.
F0791: Facility failed to assist Resident #10 in scheduling oral surgeon consultation for full mouth extractions and denture fitting after referral was received.
F0804: Facility failed to ensure food was palatable, attractive, served at safe temperature, and provided with condiments; multiple residents reported poor food quality and test tray items were cold and bland.
F0806: Facility failed to honor Resident #24's vegetarian food preference and did not provide appropriate vegetarian meal options.
F0925: Facility failed to maintain effective pest control program; flies were pervasive in kitchen, dining rooms, resident rooms, and hallways with unresolved pest control issues documented.
Report Facts
Resident census: 93
Call light response times: 175
Podiatry visits attempted: 3
CNA training files reviewed: 5
Flies observed: Flies observed throughout facility including kitchen, dining rooms, resident rooms, and hallways
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSD #2 | Social Services Director | Interviewed regarding resident behaviors, dental services, and pest control |
| NHA | Nursing Home Administrator | Interviewed regarding call light response, abuse incidents, pest control, and facility policies |
| DON | Director of Nursing | Interviewed regarding dementia care, resident altercations, and staff training |
| CNA #3 | Certified Nurse Aide | Interviewed regarding call light system, resident altercations, and pest control |
| DS | Dietary Supervisor | Interviewed regarding food quality, vegetarian diet, and pest control |
| RN #1 | Registered Nurse | Interviewed regarding foot care and skin assessments |
Inspection Report
Deficiencies: 0
Date: May 10, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home regulatory inspection.
Findings
No health deficiencies were found during the inspection.
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