Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
44% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to timely notify a resident's representative of a change in condition following a fall.
Complaint Details
The investigation was complaint-driven regarding failure to notify the resident's representative of a fall and related medical actions. The complaint was substantiated with findings confirming delayed notification.
Findings
The facility failed to timely notify Resident #176's representative of a fall, the need for medical imaging, new pain medication orders, and a diagnostic imaging appointment. Notification occurred approximately 17 hours after the fall, despite facility policy requiring prompt communication.
Deficiencies (1)
F 0580: The facility failed to immediately notify the resident's representative of a fall, medical imaging, new pain medication orders, and a CT scan appointment for Resident #176. Notification was delayed by approximately 17 hours after the fall occurred.
Report Facts
Residents reviewed: 49
Residents affected: 5
Notification delay: 17
Medication dosage: 50
Medication dosage: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectation to notify responsible party after a fall | |
| Regional Clinical Resource | Interviewed regarding notification procedures | |
| Primary Care Physician #1 | Interviewed regarding communication with family about resident's fall and care | |
| SW #1 | Social Worker | Provided notification call to resident's representative about fall and Xray results |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 3, 2025
Visit Reason
Routine inspection of a nursing home facility to assess compliance with regulatory requirements including resident care, infection control, medication management, safety, and food service.
Findings
The facility was found deficient in multiple areas including failure to timely notify a resident's representative of a change in condition, inadequate assistance with activities of daily living, incomplete documentation of resuscitation orders, failure to prevent elopement from a secured unit, incomplete dialysis documentation, failure to provide appropriate dementia care, improper medication storage, serving unpalatable food, and failure to follow infection prevention protocols.
Deficiencies (9)
F 0580: The facility failed to timely notify Resident #176's representative of a fall, Xray, new pain medication orders, and CT scan appointment, approximately 17 hours after the fall occurred.
F 0677: The facility failed to provide necessary assistance with toileting and repositioning for Residents #326 and #8, resulting in prolonged periods without care.
F 0678: The facility failed to document Resident #376's cardiopulmonary resuscitation (CPR) wishes accurately in the medical record and care plan.
F 0689: The facility failed to prevent elopement of Resident #276 from the secured unit due to inadequate supervision and a door malfunction.
F 0698: The facility failed to ensure consistent and complete dialysis communication and documentation for Resident #116, including missing vital signs and dialysis center reports.
F 0744: The facility failed to effectively identify and implement person-centered dementia care approaches for Resident #276, including failure to redirect behaviors and provide meaningful activities.
F 0761: The facility failed to ensure medications not administered were not left unsecured at Resident #101's bedside, including lidocaine cream and diclofenac gel without physician orders.
F 0804: The facility failed to consistently serve palatable food, including dry, flavorless chicken, missing pineapple in Hawaiian rice, and serving green peas instead of snap peas as posted on the menu.
F 0880: The facility failed to ensure staff wore appropriate personal protective equipment (gowns and gloves) when providing care to Residents #326 and #95 on enhanced barrier precautions for pressure wounds.
Report Facts
Residents reviewed: 49
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding medication storage and administration for Resident #101 |
| CNA #1 | Certified Nurse Aide | Observed and interviewed regarding infection control PPE use for Resident #95 |
| CNA #2 | Certified Nurse Aide | Observed providing care without gown for Resident #326 |
| CNA #3 | Certified Nurse Aide | Observed providing care without gown for Resident #326 and interviewed about PPE |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding dialysis communication documentation for Resident #116 |
| Social Worker #3 | Social Worker | Interviewed regarding dementia care interventions for Resident #276 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including notification, dialysis, and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding food preparation and quality |
| Food and Nutrition Resource | Food and Nutrition Resource | Interviewed regarding food quality and preparation |
| Nursing Home Administrator | Nursing Home Administrator | Provided statements and interviewed regarding multiple deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide and document sufficient preparation and orientation to ensure a safe discharge for Resident #191, specifically the failure to arrange home health services as ordered by the physician.
Complaint Details
The complaint investigation found that Resident #191 was discharged without home health services in place despite physician orders. The preferred home health agency declined the referral due to staffing shortages, and the facility failed to follow up or arrange alternate services. The resident suffered a fall and injury at home without proper care. The complaint was substantiated with minimal harm identified.
Findings
The facility failed to confirm and document that home health services were arranged for Resident #191 upon discharge, resulting in the resident being discharged home alone without home health care in place. This failure led to unsafe conditions, including a fall and injury requiring emergency care. The preferred home health agency declined the referral due to staffing issues, and the facility did not follow up to arrange alternate services.
Deficiencies (1)
F 0624: The facility failed to provide evidence and documented confirmation that home health services were arranged upon Resident #191's discharge, per physician orders. This resulted in an unsafe discharge with the resident lacking necessary home health care.
Report Facts
Residents in sample: 53
Residents affected: 1
Date of discharge: Feb 4, 2024
Date of survey completion: Mar 11, 2024
BIMS score: 15
Days without home health care: 15
Stitches required: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding lack of confirmation of home health services |
| Director of Nursing | DON | Interviewed about discharge process and communication with home health |
| Social Services Assistant | SSA | Case manager who arranged Resident #191's discharge and referral |
| Home Health Referral Coordinator | HHRC | Provided information that home health agency declined referral due to staffing |
| Home Health Director of Nursing | HHDON | Provided explanation for home health agency declining referral |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 11, 2024
Visit Reason
Routine state inspection survey of the nursing home facility to assess compliance with regulatory requirements including resident rights, abuse prevention, secure unit placement, discharge planning, ancillary services, fall prevention, respiratory care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to respect residents' rights regarding personal belongings, failure to post state agency contact information, failure to prevent resident-to-resident abuse, failure to document and justify secure unit placement, failure to ensure safe discharge planning with home health services, failure to assist with vision services, failure to implement effective fall prevention interventions, failure to provide adequate nutritional assistance leading to significant weight loss, failure to provide ordered oxygen therapy and monitor oxygen saturation properly, and failure to maintain infection control practices during wound care.
Deficiencies (9)
F 0557: Facility failed to obtain permission from residents #11 and #51 before searching and confiscating items from their rooms, violating residents' rights to dignity and personal possessions.
F 0575: Facility failed to post names, addresses, and telephone numbers of pertinent state agencies and advocacy groups in a manner accessible to residents.
F 0600: Facility failed to prevent a resident-to-resident physical altercation between Residents #6 and #56 and failed to properly investigate and report the incident.
F 0603: Facility failed to ensure secure unit placement for Resident #19 was properly documented with physician orders, least restrictive alternatives, and independent reviewer signature.
F 0624: Facility failed to provide and document sufficient preparation and orientation for Resident #191's discharge, including failure to ensure home health services were arranged per physician orders.
F 0685: Facility failed to assist Resident #60 with arranging an optometry appointment despite resident requests and care plan needs.
F 0689: Facility failed to implement effective fall prevention interventions for Residents #95, #12, and #19, resulting in falls with injury and inadequate monitoring and documentation of interventions.
F 0695: Facility failed to provide ordered oxygen therapy and monitor oxygen saturation levels appropriately for Resident #101, including failure to maintain oxygen flow rate and document parameters.
F 0880: Facility failed to follow clean technique during wound care for Resident #72 and failed to properly clean and disinfect wound care scissors according to standards of practice.
Report Facts
Weight loss: 18.6
Weight loss percentage: 15.02
Oxygen flow rate: 5
Oxygen saturation: 89
Oxygen saturation: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed providing wound care to Resident #72 and failed to follow clean technique and proper disinfection. |
| LPN #3 | Licensed Practical Nurse | Observed providing wound care to Resident #72 and failed to properly disinfect wound cleanser bottle handle. |
| CNA #11 | Certified Nurse Aide | Provided feeding assistance to Resident #26 during meal observations. |
| DON | Director of Nursing | Interviewed regarding multiple findings including fall prevention, oxygen therapy, colostomy care, and discharge planning. |
| NP | Nurse Practitioner | Interviewed regarding Resident #26's nutritional status and Resident #101's oxygen therapy. |
| SSD | Social Services Director | Interviewed regarding discharge planning and ancillary services. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 6, 2023
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility failed to honor resident bathing preferences for three residents, failed to provide timely admission agreements and resident rights documentation for one resident, and failed to ensure specialized rehabilitative services were provided to maintain the highest practicable level of functioning for one resident.
Deficiencies (3)
F 0561: The facility failed to honor the bathing preferences of Residents #2, #3, and #7, providing bed baths instead of preferred showers and not maintaining scheduled shower days.
F 0572: The facility failed to provide Resident #1 with an admission agreement containing resident rights and regulations until months after admission.
F 0825: The facility failed to provide specialized rehabilitative services for Resident #2, who had physician orders for therapy but did not receive evaluations or treatments timely, resulting in potential functional decline.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding shower charting and resident bathing preferences |
| Certified Nurse Aide #4 | Certified Nurse Aide | Interviewed regarding shower charting and resident bathing preferences |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding bathing preferences, shower charting, and therapy services |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed regarding admission agreement responsibilities |
| Admission Coordinator | Admission Coordinator (AC) | Interviewed regarding admission agreement process and signature collection |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding admission agreements and facility policies |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Interviewed regarding therapy services provided to Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Dec 5, 2022
Visit Reason
The inspection was conducted to investigate complaints related to resident rights, environment safety, food quality, resident grievances, abuse prevention, dementia care, activities programming, and fall prevention at the nursing home.
Complaint Details
The complaint investigation revealed substantiated issues with resident rights, environment safety, food quality, grievance handling, abuse prevention, dementia care, activities programming, and fall prevention. Multiple resident falls with injuries and resident-to-resident altercations were documented. The facility failed to adequately address these concerns.
Findings
The facility failed to ensure residents' rights to formulate advance directives, maintain a safe and clean environment, respond adequately to food-related grievances, prevent resident-to-resident abuse in the memory care unit, provide meaningful activities tailored to resident needs, and implement effective fall prevention interventions. Multiple resident falls resulted in injuries including fractures and lacerations.
Deficiencies (7)
F578: The facility failed to ensure Resident #116's medical orders for scope of treatment forms were accurately completed, signed by the resident or legal decision maker, and legal paperwork for power of attorney was obtained.
F584: The facility failed to provide a clean, safe, homelike environment, with issues including unpainted plaster repairs, damaged walls and doors, soiled bathroom call cords, and disrepair in shower rooms.
F585: The facility failed to satisfactorily respond to resident grievances regarding food quality, including cold meals, order errors, and lack of staff responsiveness.
F600: The facility failed to prevent multiple resident-to-resident altercations in the memory care unit and did not substantiate abuse allegations despite witnessed incidents.
F679: The facility failed to provide meaningful activities and social engagement tailored to residents' preferences and needs, including lack of adapted programming for visual deficits and insufficient access to independent activities.
F689: The facility failed to ensure adequate supervision and fall prevention interventions for residents at high fall risk, resulting in multiple falls with injuries including fractures and lacerations.
F744: The facility failed to provide appropriate dementia care services to prevent resident-to-resident altercations and to implement person-centered approaches in the memory care unit.
Report Facts
Sample residents reviewed: 55
Residents affected by deficiencies: 7
Resident falls: 7
Social visits scheduled: 3
Fall risk assessment score: 5
BIMS scores: 3
BIMS scores: 11
BIMS scores: 5
BIMS scores: 3
BIMS scores: 4
BIMS scores: 8
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