Inspection Reports for
Rowan Community, Inc.
4601 E ASBURY CIR, DENVER, CO, 80222-4722
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
92% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to honor residents' rights to dignity, self-determination, and proper care, including respect for resident preferences and timely assistance with activities of daily living.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to respect residents' dignity and preferences, failed to assist a resident in returning to his room promptly, and failed to provide timely repositioning and incontinence care. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure residents were treated with respect and dignity, including knocking before entering rooms and honoring mask preferences. The facility also failed to assist a resident in returning to his room timely and did not provide timely repositioning and incontinence care for dependent residents.
Deficiencies (3)
F 0550: The facility failed to ensure one resident was treated with respect and dignity by not knocking before entering the room and not wearing a face mask as requested by the resident.
F 0561: The facility failed to facilitate resident self-determination by not honoring a resident's choice to return to his room in a timely manner.
F 0677: The facility failed to provide necessary care for two residents by not ensuring timely repositioning and incontinence care, resulting in residents sitting in soiled briefs and not being repositioned for over two hours.
Report Facts
Residents in sample: 14
Residents affected: 5
Observation times: 1
BIMS scores: 12
BIMS scores: 15
BIMS scores: 0
Inspection Report
Routine
Deficiencies: 10
Date: May 22, 2025
Visit Reason
Routine inspection of Rowan Community, Inc nursing home to assess compliance with regulatory requirements including resident rights, care, safety, behavioral health, hospice, dental, and infection control.
Findings
The facility was found deficient in multiple areas including failure to respond timely to call lights, failure to protect residents from abuse, inadequate monitoring of antipsychotic medication side effects, failure to provide appropriate restorative nursing care, inadequate fall prevention and supervision, failure to provide necessary behavioral health care and safety planning, failure to ensure timely dental services, failure to ensure hospice services met professional standards, and failure to maintain an effective infection control program.
Deficiencies (10)
F550: The facility failed to ensure residents' rights to dignity and timely response to call lights for Residents #6 and #51. Resident #6's call light was frequently unanswered for long periods, causing distress. Resident #51 was not treated with respect and dignity, with staff failing to knock or identify themselves during care.
F585: The facility failed to maintain a system to document and resolve grievances for Resident #6. Two grievances submitted by the resident's representative lacked documentation of follow-up or resolution communication.
F600: The facility failed to protect Resident #51 from verbal and physical abuse by two certified nurse aides, substantiated by video evidence showing rough handling and aggressive verbal interactions.
F605: The facility failed to ensure timely and appropriate monitoring of Resident #18 for tardive dyskinesia related to antipsychotic medication. AIMS assessments were not completed quarterly as required, and side effect monitoring was inadequate.
F688: The facility failed to provide appropriate restorative nursing care for Resident #6 by not administering the ordered foot drop boot due to lack of scheduling and documentation, despite the resident's need for contracture management.
F689: The facility failed to ensure adequate supervision and fall prevention for Resident #51, who experienced 21 falls with delayed and incomplete fall investigations, lack of timely interventions, and inconsistent implementation of fall prevention measures.
F740: The facility failed to provide necessary behavioral health care and safety planning for Resident #16, who had multiple suicidal ideations and attempts. Safety plans were not timely implemented or incorporated into care plans, and frequent monitoring was inconsistently documented.
F791: The facility failed to ensure timely dental services for Resident #18 by not arranging or documenting a referral for removal of permanent dental implants needed for new dentures.
F849: The facility failed to ensure hospice services met professional standards for Residents #48 and #38 by lacking communication processes, inconsistent documentation of hospice visits, and delays in replacing broken durable medical equipment.
F880: The facility failed to maintain an effective infection control program on one unit by not ensuring housekeeping staff followed proper cleaning techniques, used separate cleaning rags for different sides of double occupancy rooms, disinfected high-touch areas, and performed hand hygiene with glove changes.
Report Facts
Call light response delays: 57
Call light response delays: 18
Falls: 21
AIMS assessment delay: 8
Frequent monitoring missing days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Interviewed regarding call light response delays and resident frustration | |
| Registered Nurse #1 | Interviewed regarding call light response and abuse allegations | |
| Director of Nursing | DON | Interviewed regarding call light response, abuse, restorative care, fall prevention, behavioral health, hospice, and infection control |
| Nursing Home Administrator | NHA | Interviewed regarding grievances, abuse, fall prevention, behavioral health, hospice |
| Housekeeper #1 | Observed and interviewed regarding cleaning procedures and infection control | |
| Hospice Registered Nurse #1 | HRN | Interviewed regarding hospice visits and equipment issues |
| Licensed Clinical Social Work Mentor | Interviewed regarding behavioral health and hospice coordination | |
| Social Services Assistant | SSA | Interviewed regarding dental referral coordination |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 24, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident rights, grievance resolution, care and services, medication administration, infection control, and food service.
Findings
The facility was found deficient in multiple areas including failure to provide timely access to medical records, inadequate grievance resolution, failure to assist residents with activities of daily living, improper medication administration via feeding tubes, ineffective pain management, improper storage and security of medications, serving unpalatable food at inappropriate temperatures, and lapses in infection prevention and control practices including hand hygiene and equipment sanitation.
Deficiencies (9)
F573: Facility failed to ensure prompt action was taken to honor a resident's request for medical records within two working days.
F585: Facility failed to ensure residents' grievances were resolved promptly and in writing, and failed to protect residents from retaliation.
F676: Facility failed to assist Resident #13 with showers and maintain personal hygiene, and care plan lacked person-centered interventions.
F677: Facility failed to assist Resident #3 with scheduled showers and use prescribed medicated shampoo.
F693: Facility failed to administer medications via feeding tube per professional standards and failed to check gastric residual prior to feeding.
F697: Facility failed to provide effective pain management including non-pharmacological interventions for Resident #16.
F761: Facility failed to ensure medication rooms and medication/treatment carts were locked properly when unattended by licensed nurses.
F804: Facility failed to serve food that was palatable in taste, temperature, and texture.
F880: Facility failed to maintain infection control including proper hand hygiene, cleaning of shared equipment between residents, and proper cleaning of resident rooms.
Report Facts
Pain level assessments: 8
Pain level assessments: 9
Pain level assessments: 10
Medication flush volume: 15
Medication flush volume: 60
Medication flush volume: 10
Medication flush volume: 20
Medication administration frequency: 4
Medication administration frequency: 3
Shower refusals: 4
Showers received: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide timely access to resident medical records and failure to properly address resident grievances.
Complaint Details
The complaint investigation involved Resident #52's and her legal representative's repeated requests for medical records that were not fulfilled timely or completely. Resident #52 also reported grievances about room temperature and staff responses, and Resident #209 complained about cold food being served. Both residents' grievances were not resolved satisfactorily or in writing.
Findings
The facility failed to ensure prompt access to medical records for Resident #52 and failed to resolve grievances for Residents #52 and #209 in a timely and satisfactory manner. The facility also failed to establish a grievance policy that met regulatory requirements.
Deficiencies (2)
F 0573: The facility failed to allow Resident #52 and her legal representative to obtain copies of medical records within two working days of request.
F 0585: The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and failed to provide prompt, written grievance resolutions for Residents #52 and #209.
Report Facts
Sample residents reviewed: 33
Days to respond to medical records request: 30
Date of grievance form: Mar 18, 2024
Date of grievance form: Apr 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Interviewed regarding records management and grievance resolution efforts | |
| Social Services Director (SSD) | Interviewed as grievance officer managing complaints and grievance processes | |
| Director of Medical Records (DMR) | Newly hired, responsible for processing medical records requests | |
| Dietary Manager (DM) | Interviewed regarding food service and grievance about cold meals | |
| Certified Nurse Aide (CNA) #4 | Interviewed regarding meal delivery delays and resident care | |
| Corporate Director of Clinical Services (CDCS) | Provided facility grievance policy |
Inspection Report
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Rowan Community, Inc.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 10, 2023
Visit Reason
The inspection was conducted due to complaint investigations regarding allegations of abuse, failure to provide adequate care, medication errors, food safety concerns, and infection control deficiencies at Rowan Community, Inc.
Complaint Details
The complaint investigation was substantiated with findings of sexual abuse, inadequate care, medication errors, food safety violations, and infection control failures.
Findings
The facility was found to have multiple deficiencies including failure to prevent sexual abuse between residents, inadequate oral care for a dependent resident, a medication error rate of 20% with insulin pen administration errors, unsafe food holding temperatures and sanitation practices, and inadequate infection control practices including improper cleaning of isolation rooms and medication administration hygiene.
Deficiencies (6)
F0600: The facility failed to prevent sexual abuse of Resident #110 by Resident #23 due to inadequate supervision and incomplete investigation documentation.
F0677: The facility failed to provide oral care for Resident #49 who was dependent on staff for care, despite documented care plans and observations of poor oral hygiene.
F0759: The facility failed to ensure medication error rates were below 5%, with a 20% error rate observed including failure to prime insulin pens and incorrect medication administration.
F0760: The facility failed to keep residents free from significant medication errors, specifically failing to prime insulin pens prior to administration for Residents #32 and #260.
F0812: The facility failed to maintain safe food preparation and storage practices, including improper food holding temperatures, moisture between stacked pans, and inadequate chemical concentrations in sanitation buckets.
F0880: The facility failed to maintain an effective infection prevention and control program, including improper cleaning of isolation rooms, failure to change gloves and perform hand hygiene, cross-contamination of resident areas, and unhygienic medication administration.
Report Facts
Medication error rate: 20
Medication administration observations: 5
Chemical concentration: 200
Food holding temperature: 41
Food holding temperature: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Observed failing to prime insulin pen prior to medication administration for Resident #32. |
| RN #2 | Registered Nurse | Observed failing to prime insulin pen prior to medication administration for Resident #260 and failing to perform hand hygiene before medication preparation. |
| LPN #1 | Licensed Practical Nurse | Observed administering incorrect dose of Lactaid medication to Resident #18. |
| RN #4 | Registered Nurse | Observed administering incorrect medication to Resident #25. |
| HSKP #1 | Housekeeper | Observed failing to follow infection control protocols while cleaning isolation and non-isolation resident rooms. |
| DA #1 | Dietary Aide | Observed failing to test chemical concentration in sanitation bucket. |
| DON | Director of Nursing | Interviewed regarding medication administration and infection control deficiencies. |
| DM | Dietary Manager | Interviewed regarding food safety and sanitation deficiencies. |
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