Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to thoroughly investigate an injury of unknown origin sustained by Resident #1, which resulted in fractures requiring hospitalization and surgery.
Complaint Details
The complaint investigation focused on the facility's failure to properly investigate an injury of unknown origin sustained by Resident #1 on 5/8/25. The investigation revealed discrepancies in staff interviews and video surveillance, failure to conduct a timely RN assessment after the injury, and inadequate supervision leading to the injury.
Findings
The facility failed to conduct a thorough and consistent investigation into Resident #1's injury of unknown origin, with discrepancies between staff statements and video evidence. Additionally, the facility failed to ensure Resident #1 was assessed by a registered nurse after a significant change in condition and did not adequately supervise the resident to prevent injury related to unsafe use of bed controls.
Deficiencies (3)
F 0610: The facility failed to thoroughly investigate an injury of unknown origin for Resident #1, with conflicting staff reports and video evidence regarding the circumstances of the injury.
F 0658: The facility failed to ensure Resident #1 was assessed by a registered nurse after a significant change of condition involving fractures to the left fibula and tibia.
F 0689: The facility failed to provide adequate supervision to prevent accidents, resulting in Resident #1 lowering the bed frame onto her legs causing fractures due to unsafe use of bed controls.
Report Facts
Residents sampled: 12
Residents affected: 1
BIMS score: 7
Xray time: 2128
Call light activation duration: 558
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Assessed Resident #1 after injury, documented progress notes, involved in investigation |
| CNA #7 | Certified Nurse Aide | First to respond to Resident #1's distress, involved in investigation and witness statements |
| LPN #5 | Licensed Practical Nurse | Provided second opinion on Resident #1's injury, assisted with Xray and care |
| LPN #2 | On-call Licensed Practical Nurse | Notified DON of Resident #1's injury, coordinated physician notification |
| DON | Director of Nursing | Oversaw investigation, interviewed staff, did not personally assess Resident #1 |
| RN #1 | Registered Nurse | Interviewed about protocol for RN assessment after condition change |
| CNA #6 | Certified Nurse Aide | Interviewed about Resident #1's behavior and use of bed controls |
| LPN #8 | Licensed Practical Nurse | Interviewed about Resident #1's condition and behavior post-injury |
| COTA | Certified Occupational Therapy Assistant | Provided therapy to Resident #1, described resident's limited transfer ability |
| MD | Medical Director | Reviewed medical record and facility leadership's conclusions about bed safety |
| NHA | Nursing Home Administrator | Demonstrated injury scenario and discussed bed controller safety concerns |
Inspection Report
Routine
Deficiencies: 2
Date: May 9, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, hygiene, and food service quality at Orchard Park Health Care Center.
Findings
The facility failed to provide adequate fingernail care and bathing assistance to residents #65 and #69, resulting in long, chipped, and dirty fingernails and dry skin. Additionally, the facility failed to consistently serve food that was palatable, attractive, and at safe temperatures, with issues noted in taste, texture, and temperature of meals served.
Deficiencies (2)
F 0677: The facility failed to ensure Resident #65's fingernails were trimmed and clean and Resident #69 received staff assistance with fingernail care, lotion application, and showering. Observations showed long, chipped, and dirty fingernails and inadequate bathing assistance.
F 0804: The facility failed to consistently serve food that was palatable, attractive, and at safe temperatures. Meals were often cold, bland, or improperly textured, and cheesecake pudding pies were served above safe temperature ranges.
Report Facts
Residents reviewed for ADL assistance: 45
Residents affected: 2
Showering assistance provided: 2
BIMS score: 10
BIMS score: 15
Cheesecake pudding pie temperature: 52
Cheesecake pudding pie temperature: 73
Cheesecake pudding pie temperature: 49
Inspection Report
Routine
Deficiencies: 2
Date: May 9, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, hygiene, and food service quality at Orchard Park Health Care Center.
Findings
The facility failed to provide adequate fingernail care and bathing assistance to residents #65 and #69, resulting in long, chipped, and dirty fingernails and dry skin. Additionally, the facility failed to consistently serve food that was palatable, attractive, and at safe temperatures, with issues noted in taste, texture, and temperature of meals served.
Deficiencies (2)
F 0677: The facility failed to ensure Resident #65's fingernails were trimmed and clean and Resident #69 received staff assistance with fingernail care, lotion application, and showering.
F 0804: The facility failed to consistently serve food that was palatable in taste, temperature, and texture, including cold meals and improperly prepared pureed diets.
Report Facts
Residents reviewed for ADL assistance: 45
Residents reviewed for fingernail care: 5
Residents affected by fingernail care deficiency: 2
Showering assistance opportunities for Resident #69: 8
Bathing assistance received by Resident #69: 2
Temperature of crusted cheesecake pie: 52
Temperature of crustless cheesecake pie: 73
Temperature of leftover cheesecake pies in refrigerator: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in failure to provide fingernail care to Resident #65 despite assisting with shower. |
| RN #1 | Registered Nurse | Interviewed regarding responsibility for fingernail care and Resident #65's condition. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding staff responsibility for fingernail care and plans for education. |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #69's shower schedule and nail care. |
| RN #2 | Registered Nurse | Interviewed about Resident #69's shower and nail care schedule. |
| CNA #2 | Certified Nurse Aide | Interviewed about Resident #69's preferences and shower assistance. |
| DM #1 | Dietary Manager | Interviewed about food temperature and quality issues. |
| DM #2 | Dietary Manager | Interviewed about food texture issues and staff education. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 26, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident care, communication, activities, wound care, and dietary services at Orchard Park Health Care Center.
Complaint Details
The complaint investigation focused on issues including failure to honor resident bathing preferences, inadequate care planning for nutritional and social needs, ineffective communication with non-English speaking residents, insufficient activity provision, improper wound care, and failure to accommodate dietary restrictions.
Findings
The facility failed to honor resident bathing preferences, develop comprehensive care plans addressing nutritional and socialization needs, provide effective communication aids for residents with language barriers, ensure proper wound care for pressure ulcers, and accommodate dietary restrictions such as gluten-free diets.
Deficiencies (6)
F 0561: The facility failed to honor Resident #357's bathing preference by providing bathing during the night instead of the preferred daytime.
F 0656: The facility failed to develop comprehensive care plans addressing nutritional needs for Residents #51 and #82, including goals and person-centered interventions.
F 0676: The facility failed to provide effective communication strategies and auxiliary aids for Residents #5 and #23 who spoke languages other than English.
F 0679: The facility failed to provide activities meeting Resident #36's socialization needs, including one-to-one or independent activities.
F 0686: The facility failed to ensure Resident #62 received prescribed wound treatment with Triad cream after every incontinence episode for a coccyx pressure ulcer.
F 0806: The facility failed to honor Resident #28's gluten-free dietary preferences and did not consistently provide gluten-free food items and desserts.
Report Facts
Sample residents reviewed: 50
Residents affected by bathing preference deficiency: 1
Residents affected by care plan deficiency: 2
Residents affected by communication deficiency: 2
Residents affected by activity deficiency: 1
Residents affected by wound care deficiency: 1
Residents affected by dietary deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed regarding Resident #357's bathing schedule. |
| RN #1 | Registered Nurse | Interviewed regarding Resident #357's bathing schedule. |
| Director of Nursing | Director of Nursing | Interviewed regarding bathing schedules, care plans, and communication tools. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutritional care plans for Residents #51 and #82. |
| Activities Director | Activities Director | Interviewed regarding socialization activities for Resident #36. |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding wound care for Resident #62. |
| Dietary Manager | Dietary Manager | Interviewed regarding gluten-free diet provision for Resident #28. |
| Corporate Consultant | Corporate Consultant | Interviewed regarding action plan for gluten-free diet compliance. |
| Registered Dietitian | Registered Dietitian | Interviewed with Corporate Consultant regarding gluten-free diet compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 14, 2021
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure that registered nurse assessments were completed and documented following falls sustained by Resident #9.
Complaint Details
The complaint investigation found that the facility did not substantiate that RN assessments were completed after Resident #9's falls on 9/3/21, 10/2/21, and 10/6/21. Interviews with staff confirmed the absence of documented RN assessments.
Findings
The facility failed to ensure that a registered nurse completed and documented assessments after Resident #9 sustained multiple falls on 9/3/21, 10/2/21, and 10/6/21. Licensed practical nurses completed change of condition notes, but no RN assessments were documented in the resident's medical record.
Deficiencies (1)
F 0658: The facility failed to ensure an assessment was completed and documented by a registered nurse following falls sustained by Resident #9 on multiple occasions. Licensed practical nurses completed progress notes, but RN assessments were not documented.
Report Facts
Residents sampled: 39
Falls sustained by Resident #9: 3
Length of abrasion: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Completed change of condition notes and interviewed regarding RN assessment scope | |
| Director of Nursing (DON) | Interviewed about RN assessment requirements and documentation | |
| Regional Nurse Consultant (RNC) | Interviewed RNs and confirmed lack of documented RN assessments |
Report
June 19, 2025
Report
May 9, 2024
Report
May 9, 2024
Report
January 26, 2023
Report
October 14, 2021
Viewing
Loading inspection reports...
