Inspection Reports for
The Center at Lincoln, LLC
12230 LIONESS WAY, PARKER, CO, 80134-5603
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and fall prevention for Resident #1, who sustained multiple falls resulting in a major injury.
Complaint Details
The investigation was triggered by complaints about inadequate supervision leading to falls for Resident #1. The falls were substantiated, with findings confirming failure to follow fall prevention protocols and supervision requirements.
Findings
The facility failed to ensure adequate supervision and consistent implementation of fall prevention interventions for Resident #1, a high fall risk resident, resulting in two unwitnessed falls and a left femur fracture. Staff left the resident unattended during showering, contrary to care plans and facility policies.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. Resident #1, a high fall risk, sustained two unwitnessed falls due to inadequate supervision, resulting in a left femur fracture.
Report Facts
Residents reviewed for accidents: 5
Falls sustained by Resident #1: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Left Resident #1 unattended in the shower, leading to fall and fracture. |
| LPN #1 | Licensed Practical Nurse | Assigned nurse on 10/24/25, assessed Resident #1 after fall and reported incident. |
| CNA #3 | Certified Nurse Aide | Interviewed about fall risk procedures and supervision. |
| CNA #1 | Certified Nurse Aide | Interviewed about Resident #1's fall risk and supervision. |
| CNA #4 | Certified Nurse Aide | Interviewed about fall risk procedures and resident supervision. |
| Director of Nursing | Director of Nursing (DON) | Provided information on fall care plan and staff education. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided information on fall care plan and staff education. |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding fall care plan and facility procedures. |
Inspection Report
Routine
Deficiencies: 12
Date: Nov 21, 2024
Visit Reason
Routine state inspection survey of Center at Lincoln, Llc nursing home for compliance with healthcare regulations.
Findings
The facility had multiple deficiencies including failure to obtain timely informed consent for psychotropic medication, failure to honor resident bathing preferences, misappropriation of resident property, failure to provide baseline care plans within 48 hours, ineffective discharge planning, inadequate activities programming, failure to provide appropriate wound care and infection control, failure to provide palatable and properly served food, failure to maintain sanitary food preparation and storage, failure to implement enhanced barrier precautions (EBP) properly, failure to wear appropriate PPE in COVID-19 positive rooms, and failure to provide effective pain management.
Deficiencies (12)
F 0552: Facility failed to ensure informed consent was obtained prior to administration of psychotropic medication for Resident #226.
F 0561: Facility failed to honor Resident #53's preference to have her bed bath completed during the day shift.
F 0602: Facility failed to prevent misappropriation of property for Residents #228, #46, and #229 during their stay.
F 0655: Facility failed to provide baseline care plans within 48 hours of admission for Residents #380, #376, #382, and #225.
F 0660: Facility failed to develop and implement effective discharge plans for nine residents, including lack of resident/family involvement and documentation.
F 0679: Facility failed to provide activities designed to meet residents' physical, mental, and psychosocial needs for Residents #373 and #36.
F 0684: Facility failed to provide appropriate wound care and infection control for Resident #53, including improper wound cleaning technique and delayed referral to wound physician.
F 0686: Facility failed to ensure Resident #174 wore physician-ordered heel protection boots consistently to prevent pressure ulcers.
F 0697: Facility failed to provide effective pain management for Resident #382, who experienced acute pain and was not given timely analgesic medication.
F 0804: Facility failed to consistently serve palatable, attractive food at safe temperatures as reported by multiple residents and observed during meal service.
F 0812: Facility failed to ensure food was prepared, distributed and served under sanitary conditions including improper glove use and cross contamination in the kitchen and nourishment refrigerators with expired and unlabeled food.
F 0880: Facility failed to maintain an infection control program including failure to wear appropriate PPE in COVID-19 positive rooms, improper wound care infection control, failure to implement enhanced barrier precautions (EBP) for residents with wounds and indwelling devices, and failure to wear appropriate PPE for residents on EBP.
Report Facts
Residents reviewed: 60
Residents affected by misappropriation: 3
Residents affected by activities deficiency: 2
Residents affected by wound care deficiency: 1
Residents affected by heel protection deficiency: 1
Residents affected by pain management deficiency: 1
Residents affected by food palatability deficiency: 13
Residents affected by infection control deficiency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in pain management failure for Resident #382 |
| RN #1 | Registered Nurse | Named in heel protection boots failure for Resident #174 |
| CWN | Certified Wound Nurse | Named in wound care infection control failure for Resident #53 |
| DON | Director of Nursing | Named in multiple findings including wound care, pain management, and infection control |
| EC | Executive Chef | Named in food palatability and food safety deficiencies |
| CM #1 | Case Manager | Named in discharge planning deficiencies |
| CM #2 | Case Manager | Named in discharge planning deficiencies |
| IP | Infection Preventionist | Named in infection control deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide pharmaceutical services to meet the needs of a resident, specifically the failure to ensure two inhaler medications were ordered and delivered as prescribed.
Complaint Details
The complaint investigation found that the facility did not provide two inhaler medications to Resident #1 due to a pharmacy error misinterpreting admission orders as duplicate and deleting the correct medication list. The facility did not report missing medications. Pharmacy staff were counseled and updated processes to prevent recurrence.
Findings
The facility failed to provide two prescribed inhaler medications to Resident #1 during their stay from 7/7/24 to 7/9/24 due to a pharmacy error where the correct medication list was deleted. The facility initiated staff training to prevent future occurrences and the pharmacy implemented a plan of correction.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of Resident #1 by not ensuring two inhaler medications were ordered and delivered as prescribed by the physician.
Report Facts
Medication doses not administered: 3
Medication doses not administered: 2
Resident stay duration: 2
Days between hospital admission and facility admission: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication order and pharmacy communication issues | |
| Registered Nurse #1 | Interviewed about calling pharmacy to request missing medications |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jun 6, 2023
Visit Reason
The inspection was conducted due to complaints regarding grievance process failures, medication errors, food quality, infection control, housekeeping sanitation, and staff training deficiencies.
Complaint Details
The complaint investigation focused on grievances not being documented or resolved, medication errors exceeding acceptable rates, poor food quality and temperature, unsanitary kitchen conditions, inadequate infection control practices including PPE use for COVID-19, and incomplete staff training on abuse and dementia care.
Findings
The facility failed to maintain a system for documenting and resolving resident grievances, had a medication error rate above 5% due to improper insulin pen priming, stored and labeled medications improperly, served food that was often cold, bland, and unpalatable, maintained unsanitary kitchen conditions, failed to follow proper infection control and PPE protocols for COVID-19, and did not ensure all staff completed required annual training on abuse prevention and dementia care.
Deficiencies (8)
F0585: The facility failed to document and follow up on Resident #33's grievance and did not ensure residents knew how to file grievances or have access to grievance forms.
F0759: The facility failed to ensure the medication error rate was less than 5%, with a 7.89% error rate due to insulin pens not being primed before each injection for three residents.
F0760: The facility failed to keep residents free from significant medication errors by not priming insulin pens prior to administration for three residents.
F0761: The facility failed to ensure medications were properly labeled, expired medications were removed, and topical medications were stored separately from oral medications.
F0804: The facility failed to serve food that was palatable, attractive, and at safe temperatures, with multiple residents reporting bland, dry, cold, and unappealing meals.
F0812: The facility failed to maintain a clean and sanitary kitchen and properly label and seal open food items, with observations of soiled surfaces, expired food, and improper storage.
F0880: The facility failed to implement an effective infection prevention and control program, including improper PPE use by staff in COVID-19 isolation rooms and inadequate cleaning and disinfecting of resident rooms.
F0943: The facility failed to ensure two CNAs completed required annual abuse prevention training and three CNAs completed required annual dementia care training.
Report Facts
Medication error rate: 7.89
Medication errors: 3
Sample residents reviewed for medication administration: 44
CNAs reviewed for training records: 5
Expired IV bags: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed administering insulin without priming the insulin pen. |
| RN #2 | Registered Nurse | Observed administering insulin without priming the insulin pen and unaware of priming requirement. |
| DON | Director of Nursing | Provided facility policies and acknowledged medication administration errors and training deficiencies. |
| NHA | Nursing Home Administrator | Interviewed regarding grievance process, staff training deficiencies, and housekeeping policies. |
| DM | Dietary Manager | Interviewed about food quality complaints and kitchen sanitation issues. |
| HSKP #1 | Housekeeper | Observed cleaning resident rooms improperly and unaware of disinfectant contact times. |
| HSKP #2 | Housekeeper | Observed cleaning resident rooms improperly and unaware of disinfectant contact times. |
| DOM | Director of Maintenance | Interviewed about housekeeping policies, chemical use, and training needs. |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 12, 2019
Visit Reason
Routine inspection of a nursing home to assess compliance with regulatory standards including resident care, medication administration, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate assistance with activities of daily living, improper pain management, medication errors, improper infection control practices, and food safety violations related to temperature control and chemical sanitization.
Deficiencies (7)
F 0550: The facility failed to ensure three residents were treated with respect and dignity, including timely response to call lights and appropriate interaction with cognitively impaired residents.
F 0677: The facility failed to provide necessary assistance with activities of daily living for two residents, including timely incontinent care and meal assistance.
F 0694: The facility failed to ensure nurses demonstrated competency in PICC line care, including lack of orders for blood draws, improper blood discard, and uncertified staff performing PICC line procedures.
F 0697: The facility failed to follow physician prescribed pain level parameters when administering pain medications to a cognitively impaired resident and failed to offer non-pharmacological interventions for pain management.
F 0759: The facility failed to ensure medication error rates were below 5%, with a 10% error rate observed including late administration and omission of scheduled medications.
F 0812: The facility failed to maintain proper food temperatures for cold items and failed to maintain disinfectant chemicals at appropriate levels, resulting in potential food contamination.
F 0880: The facility failed to follow proper infection prevention and control practices including hand hygiene, glove use, cleaning equipment between residents, and correct use of personal protective equipment (PPE).
Report Facts
Medication pass error rate: 10
Food temperature: 58
Food temperature: 66
Food temperature: 60
Disinfectant PPM: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in PICC line care deficiency for lack of certification and improper blood draw technique. |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding inconsistent pain assessment and medication administration. |
| RN #5 | Registered Nurse | Interviewed regarding pain assessment and call light response. |
| CNA #6 | Certified Nurse Aide | Observed failing to clean equipment between residents and improper resident interaction. |
| CNA #8 | Certified Nurse Aide | Observed failing to change gloves between dirty and clean procedures during peri care. |
| Executive Chef | Executive Chef | Interviewed regarding food temperature control and disinfectant chemical use. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including infection control, pain management, and medication errors. |
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