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| Deficiency Category | Inspection Date: 11/21/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 6/15/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 4/19/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 11/21/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 11/21/24Read the full report (PDF) 10/15/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Colorado: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide activities to meet all resident's needs. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Plan the resident's discharge to meet the resident's goals and needs. | 10/15/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | 11/21/24 | 12/13/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Allow residents to self-administer drugs if determined clinically appropriate. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Few |
Assure the security of all personal funds of residents deposited with the facility. | 11/21/24 | 12/12/24 | 2 - Minimal harm or potential for actual harm | Many |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 6/15/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 11/20/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Colorado: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 3/7/24 | 6/29/24 | 3 - Actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe, appropriate pain management for a resident who requires such services. | 3/7/24 | 4/17/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/7/24 | 4/17/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/15/23 | 8/18/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Many |
Provide and implement an infection prevention and control program. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure services provided by the nursing facility meet professional standards of quality. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 3/7/24 | 6/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Few |
The resident has the right to receive notices in a format and a language he or she understands. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that residents are free from significant medication errors. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have enough outside ventilation via a window or mechanical ventilation, or both. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 3/7/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Many |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Develop, implement, and/or maintain an effective training program for all new and existing staff members. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | 6/15/23 | 8/8/23 | 2 - Minimal harm or potential for actual harm | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 6/15/23 | 7/18/23 | 2 - Minimal harm or potential for actual harm | Many |
| Date of last standard health inspection: | 4/19/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 3/23/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 7/28/22Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Colorado: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | 4/19/22 | 6/14/22 | 3 - Actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/23/23 | 4/26/23 | 3 - Actual harm | Few |
Provide or obtain dental services for each resident. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
Assist a resident in gaining access to vision and hearing services. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 4/19/22 | 6/14/22 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure staff are vaccinated for COVID-19 | 4/19/22 | 6/14/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Perform COVID19 testing on residents and staff. | 4/19/22 | 6/14/22 | 4 - Immediate jeopardy to resident health or safety | Many |
Provide and implement an infection prevention and control program. | 4/19/22 | 5/18/22 | 4 - Immediate jeopardy to resident health or safety | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure services provided by the nursing facility meet professional standards of quality. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | 4/19/22 | 6/14/22 | 3 - Actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 7/28/22 | 9/4/22 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Some |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 4/19/22 | 6/14/22 | 2 - Minimal harm or potential for actual harm | Many |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 4/19/22 | 6/14/22 | 3 - Actual harm | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 4/19/22 | 6/14/22 | 3 - Actual harm | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 4/19/22 | 6/14/22 | 3 - Actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Plan the resident's discharge to meet the resident's goals and needs. | 10/15/24 | 11/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 11/21/24 | 12/20/24 | 2 - Minimal harm or potential for actual harm | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 3/7/24 | 6/29/24 | 3 - Actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 3/7/24 | 4/17/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/7/24 | 4/17/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Many |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 3/7/24 | 6/21/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 11/20/23 | 12/18/23 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure that residents are free from significant medication errors. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Some |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 3/7/24 | 5/9/24 | 2 - Minimal harm or potential for actual harm | Many |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Develop, implement, and/or maintain an effective training program for all new and existing staff members. | 3/7/24 | 4/17/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/23/23 | 4/26/23 | 3 - Actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 7/28/22 | 9/4/22 | 2 - Minimal harm or potential for actual harm | Some |