Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center At Centerplace, Llc, The during CMS and state inspections, most recent first.
Food service failed to provide meals that were consistently palatable in taste, texture, and temperature. Residents reported cold, bland food, missing or incorrect tray items, and inconsistent meal service, while a test tray showed bland chicken fettuccine, doughy garlic bread, and a warm salad served without dressing. Resident council concerns and staff interviews also reflected ongoing problems with recipe use, tray accuracy, and meal quality.
A CNA assisted a resident with dressing after a colostomy leak but wore gloves only and did not don a gown despite the resident being on EBP and a gown bin being outside the room. In a separate event, a CNA used shared vital signs equipment on multiple residents, including residents in rooms with EBP signs, without cleaning the equipment between residents; the DON stated the equipment must be disinfected after use and between each resident.
A resident who was cognitively intact and needed substantial to maximal help with ADLs reported that her stuffed animal went missing after a shower. Staff helped look for it, but no grievance form was completed when the loss was first reported, and the issue was not formally documented until later during the survey. The grievance was not resolved until 17 days after the item was first reported missing, despite staff and the DON stating that missing personal items should be addressed immediately and usually within 72 hours.
A resident with dementia, weakness, and prior unwitnessed falls was not adequately supervised during showering and fell while standing to wash his groin. The resident slipped on the wet surface, hit his head, and sustained a skin tear and abrasion. Staff interviews and the record showed the CNA left the bathroom to retrieve items, and the resident’s fall risk was not reassessed after prior falls.
A resident with respiratory failure, asthma, lung disorders, and CHF did not receive fully coordinated BiPAP care. The resident’s chart showed nighttime BiPAP orders, but a physician note also directed daytime use for 2 to 3 hours because of hypercapnia, and the facility did not implement that daytime use until during the survey. The care plan also lacked instructions for cleaning, sanitizing, and storing the BiPAP mask, and the mask was observed left on the nightstand without a protective covering and with hair on it.
A resident receiving dialysis was not provided care consistent with dialysis center recommendations. The resident had ESRD, DM2, and nutritional anemia, and the dialysis center recommended a 1.5 L fluid restriction plus a high-protein, low-potassium, low-sodium renal/cardiac diet. The resident remained on a liberal renal CCHO diet, the EMR lacked documentation that staff clarified or followed up on the recommendations, and the RN, DON, and NP gave conflicting accounts about whether the physician and dietary team were informed.
Medication Errors: BP Meds Given Outside Parameters Two cognitively intact residents with HTN had ordered hold parameters for antihypertensive meds, but the meds were still administered when SBP and, in one case, HR were below the physician’s limits. The EMR did not include progress notes explaining why the meds were given despite the ordered parameters.
Expired insulin, testing supplies, and Banatrol Plus packets were found in medication carts and medication storage rooms. An expired Insulin Lispro pen for a resident was observed in one cart, while expired E-swab and urine collection kits and expired blood collection kits were found in a storage room. Additional expired Banatrol Plus packets were found in another cart and storage room, and staff acknowledged the items were expired.
A resident with multiple respiratory and cardiac conditions had a MOST form indicating a wish for CPR, but facility staff incorrectly documented the code status as DNR in the EMR, care plan, MAR, and report sheet. When the resident was found unresponsive, staff relied on the incorrect report sheet information and did not initiate CPR or contact EMS, resulting in the resident's wishes not being honored.
Missed Admission Medications and No Physician Notification A resident admitted with cellulitis, a pressure ulcer, diabetes, and respiratory failure did not receive multiple ordered meds on admission, including an IV antibiotic and several routine medications, because they were documented as not available. Some of the meds were already available at the facility, and the record did not show that the physician was notified about the missed doses. Staff interviews confirmed that nurses were expected to verify orders, check the automated dispensing system, contact the pharmacy, and notify the physician when ordered meds could not be given.
A facility failed to manage anticoagulant therapy and respond to a resident's change in condition. The resident, on anticoagulants, showed signs of a gastrointestinal bleed but was not sent to the hospital. There was no documentation of monitoring or a full assessment, and the care plan was not updated to reflect a DNR status. This contributed to the resident's death from a presumed gastrointestinal bleed.
The facility's QAPI program failed to identify and address a critical care issue, resulting in a resident's death due to a GI bleed. The QAPI committee did not send the resident to the hospital when needed, creating an immediate jeopardy situation. Staff interviews revealed a lack of communication and awareness of the issue, with the Medical Director unaware of the incident. High staff turnover contributed to the deficiency.
A resident with moderate cognitive impairments and multiple health issues expressed a preference for showers twice a week, which was documented in her care plan. However, the facility failed to adhere to this schedule, providing showers only on four out of eight opportunities. Staff interviews revealed that the facility's policy to accommodate resident preferences and document refusals was not consistently followed, resulting in the deficiency.
The facility failed to maintain an effective infection control program, as staff did not consistently identify residents on enhanced barrier precautions (EBP) due to missing signage. A resident with wounds and a central line lacked proper EBP signage, leading to staff entering without PPE. Another resident receiving IV medications did not have EBP signage, and a nurse administered medications without a gown. Additionally, an LPN failed to perform hand hygiene or wear a gown during medication administration, despite precautionary signage.
A facility failed to maintain accurate and timely MDS assessments for a resident admitted with multiple diagnoses, including Parkinson's disease and hospice care. The admission assessment did not reflect hospice status, and the quarterly assessment was submitted late. Interviews revealed staff misunderstandings about completing the functional abilities section, despite the resident receiving skilled services, including therapy.
The facility failed to provide adequate respiratory care for two residents using CPAP machines. There were no physician's orders detailing the use and maintenance of the machines, and a routine cleaning schedule was not implemented. One resident reported using tap water instead of distilled water due to a shortage. Staff interviews confirmed the lack of adherence to expected practices, resulting in deficiencies in care.
A resident with heart disease and high blood pressure was administered Lisinopril and Carvedilol despite their blood pressure and heart rate being below the physician-specified parameters. The facility's medication administration record showed multiple instances of this error, with no supporting progress notes. Interviews with staff confirmed the error, highlighting the importance of adhering to medication hold parameters for safety.
Food Service Failed to Provide Palatable Meals
Penalty
Summary
The facility failed to ensure residents consistently received food that was palatable in taste, texture, and temperature. The facility’s standardized recipe policy stated that standardized recipes were to be used for planned menu items and that cooks/chefs were expected to follow the recipes provided. However, survey observations and interviews showed that residents were receiving meals that were bland, cold, missing items, or not consistent with what had been ordered. A resident representative reported that staff said there had been turnover in the kitchen and that whoever was in the building would take over food service responsibility because there was no cook at the moment. In a group interview, five alert and oriented residents said the food was cold, did not taste good, and was inconsistent in quality. They reported that chicken served that day was cold and bland, and that ordered items such as cranberry juice and a pickle were not delivered. Another resident said food was bland with no salt, described receiving the wrong entrée and side items, and reported difficulty getting coffee and having meal orders taken or meal tickets completed until the day before the interview. A different resident said meals were cold at lunch and dinner and that ordered items were sometimes replaced with something else because meal tickets were lost. Surveyors also evaluated a test tray for a regular diet after the last resident was served lunch. The chicken fettuccine alfredo was bland, the garlic bread was doughy, lacked garlic flavor and seasoning, and the garden salad was served warm at 90 degrees Fahrenheit with no dressing. Record review showed resident council concerns about hard, cold bread, overcooked chicken, hard-to-chew breakfast items, small drink portions, missing tray items, delays in receiving missing items, and meals not matching the tickets. Staff interviews confirmed that the dietary manager monitored food quality through tray audits and temperature checks, and the cook said he tasted the chicken that day and found it bland. The recipe reviewed for the chicken fettuccine directed salt to be added to taste, yet the meal was still described as bland.
Infection Control Failures With EBP and Shared Vital Signs Equipment
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of infection on two units. One deficiency involved Enhanced Barrier Precautions (EBP) for a resident with an EBP sign posted on the door and a bin of EBP gowns outside the room. A CNA assisted the resident with dressing after the resident’s colostomy leaked and fecal matter got onto the resident’s hospital gown and abdomen, but the CNA wore gloves only and did not put on a gown while providing this high-contact care activity. The CNA later stated she knew the resident was on EBP, but believed the gown was only required for catheter care and not for dressing assistance. The CNA said she helped the resident out of the dirty hospital gown and into a clean hospital gown while wearing only gloves. The DON, who was also the facility’s infection preventionist, stated the CNA should have worn a gown while providing care to the resident and said she educated the CNA and all direct care staff on proper EBP implementation. A second deficiency involved shared vital signs equipment. A CNA used the same vital signs equipment to assess multiple residents in succession, including residents in rooms with EBP signs posted on the doors, and did not clean the equipment between residents. Observers noted the CNA did not perform hand hygiene after leaving one room and did not wipe the equipment before entering the next room, and no cleaning wipes were available on the vital machine. The DON stated all vital signs equipment must be cleaned after use and between each resident using purple top disinfecting wipes.
Delayed Grievance Response for Missing Personal Item
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance for one resident who reported a missing personal item. The resident was cognitively intact, had diagnoses including chronic respiratory failure, type 2 diabetes, and acute pulmonary edema, and required substantial to maximal assistance with most ADLs. The resident reported that a green gecko stuffed animal had gone missing after a shower and said she had told nursing staff immediately after noticing it was missing. She was upset because she had owned the stuffed animal for over a year. Record review showed a behavior note documenting that the resident was anxious and did not know where she had misplaced her green gecko toy, but no grievance form was completed at that time. A grievance form was not completed until later during the survey, when the social services director filed one on the resident’s behalf. That grievance documented that the resident said the stuffed animal could not be located after she returned to her room after a shower and that nursing team members were not aware of any missing items. The grievance was resolved when the social services director documented that a new stuffed animal would be ordered for the resident, but this occurred 17 days after the item was first reported missing. Staff interviews indicated that missing personal items were supposed to be reported, looked for, and documented through the grievance process, typically the same day and within 72 hours. The nursing home administrator also stated that missing personal items needed to be addressed immediately or within a few days, but the grievance for the resident’s missing stuffed animal was not filed until later and was not handled promptly.
Inadequate Supervision During Showering for a Resident With Prior Falls
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision for one resident who had a history of falls and required assistance with activities of daily living. The resident had diagnoses including pneumonia, dementia with agitation, and generalized muscle weakness, and the MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required partial to maximal assistance for most ADLs and maximal assistance for most transfers. The record also showed prior unwitnessed falls, including a fall on 3/29/26 and another on 4/20/26, with the resident identified as being at risk for falls due to impaired mobility, weakness, debility, and drug regimen. After the 3/29/26 fall, the record documented that the resident reported falling while adjusting sheets and that the fall was unwitnessed. A root cause analysis identified likely causes as an unassisted transfer, impaired safety awareness, and environmental weakness. The resident’s EMR did not show that the fall risk was reassessed after that fall. The resident’s care plan and Kardex later included interventions such as increased observation, keeping the environment well-lit and free of clutter, reinforcing call light use, and not leaving the resident alone in the bathroom. On 4/20/26, the resident fell again while showering. The resident reported that he was washing his groin, reached for the grab bar, slipped, and fell backward, hitting his head and sustaining a skin tear to the right upper arm and an abrasion to the mid-back. The resident was found sitting on the floor with his buttocks outside the shower and his legs in the shower. The CNA involved reported that the resident was standing while washing his groin when his feet slipped. Staff interviews showed that the CNA left the bathroom to retrieve the resident’s clothes, and the resident stated that a staff member had left to get towels when he fell. The resident’s EMR did not show a reassessment of fall risk after this fall either.
BiPAP Care Not Fully Ordered or Planned
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for one resident who required BiPAP therapy. Resident #37 had diagnoses including acute and chronic respiratory failure with hypercapnia, unspecified asthma, other lung disorders, and congestive heart failure. The resident was cognitively intact, required substantial assistance with several activities of daily living, and reported using BiPAP at night and during daytime naps. During observation, the BiPAP mask and tubing were left on the nightstand without a protective covering, and hair was noted on the outside of the mask. The resident stated the mask had not been cleaned since admission and that staff placed the BiPAP on the nightstand each morning after removing it. Record review showed the physician’s order for BiPAP specified nighttime use with settings of 12/5, a flex of 2, a Respironics DreamWear small nasal cushion and frame, and 2 liters per minute of supplemental oxygen. A physician progress note documented that the resident may require BiPAP more frequently during the daytime because of a tendency to develop hypercapnia and stated pulmonology instructed her to wear BiPAP for two to three hours during the day regardless of napping. The electronic medical record showed the facility did not implement daytime BiPAP use until during the survey, and the care plan did not include daytime BiPAP use. The care plan also did not include instructions for cleaning, sanitizing, or storing the BiPAP mask. Staff interviews showed differing understanding of the BiPAP requirements: one RN said there was no order for daytime use and that nurses generally reviewed progress notes and updated orders as needed, while a CNA said the resident only wore BiPAP at night and was not prescribed daytime use. The DON acknowledged the facility should have followed the physician’s order for daytime BiPAP use and that the mask should have been cleaned according to manufacturer recommendations, but the resident’s care plan and orders did not reflect those instructions at the time of the deficiency.
Dialysis Recommendations Not Implemented for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care had the dialysis center’s recommendations implemented and communicated through the resident’s orders and care processes. Resident #15 had end stage renal disease, dependence on renal dialysis, nutritional anemia, and type 2 diabetes, and the April 2026 MDS indicated she was cognitively intact, required assistance with several activities of daily living, was receiving dialysis, and was on a therapeutic diet. Record review showed the dialysis center issued a 4/13/26 communication recommending a fluid restriction of 1.5 liters per day and a 4/15/26 communication recommending a high protein, low potassium, low sodium, renal and cardiac friendly diet. The resident’s physician orders did not include either recommendation; instead, the resident remained on a liberal renal CCHO diet. The EMR did not show documentation that the facility followed up on, addressed, or clarified the dialysis center’s recommendations, and there was no documentation that the physician was contacted about the diet or fluid changes. Interviews showed inconsistent handling of the dialysis communication forms. An RN stated she reviewed the form and completed a diet communication form but did not follow up with dietary staff and did not contact the physician. The DON stated nurses were responsible for reviewing dialysis forms, contacting the physician, and communicating with the IDT when recommendations were made. The NP stated she was not aware of the diet recommendations or fluid restriction because the nurses did not inform her, and the medical director later stated the facility physician decided there was no need for the fluid or dietary restriction, although the record did not show that the fluid restriction recommendation had been reviewed by the physician.
Medication Errors: Blood Pressure Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for two residents reviewed for medication errors. One resident had diagnoses including hypertension and peripheral vascular disease and was cognitively intact with a BIMS score of 15 out of 15. The resident’s April 2026 physician orders included amlodipine 10 mg in the morning for hypertension, to be held if systolic blood pressure was less than 110 mmHg, and losartan 100 mg in the morning for hypertension, also to be held if systolic blood pressure was less than 110 mmHg. Review of vital signs from 3/1/26 to 4/20/26 showed eight occasions when systolic blood pressure was below 110 mmHg, yet the blood pressure medication was still administered. The resident’s EMR did not contain progress notes explaining why the medications were given despite the ordered hold parameters. A second resident had diagnoses including hypertension and stage three kidney disease and was also cognitively intact with a BIMS score of 15 out of 15. The resident’s April 2026 physician orders included lisinopril 20 mg in the morning for hypertension, to be held if systolic blood pressure was less than 110 mmHg, and propranolol 20 mg twice daily for migraines, to be held if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 bpm. The EMR showed blood pressure readings of 108/58 mmHg and 103/65 mmHg on two occasions, and a heart rate of 54 bpm on another occasion, but the medications were still administered. The resident’s EMR did not include progress notes to explain why the medications were given outside the ordered parameters.
Expired medications, testing supplies, and supplements found in medication storage areas
Penalty
Summary
The facility failed to provide proper storage for medical supplies and supplements in two medication carts and two medication storage rooms. During observations, an expired Insulin Lispro pen for Resident #21 was found in the second-floor medication cart, along with expired testing supplies in the third-floor medication storage room, including an E-swab collection kit, a urine collection kit, and two expired boxes of safety winged blood collection kits. RN #1 acknowledged that the swabs and urine collection system had expired and could not be used because they contained a preservative liquid. The third-floor medication cart and third-floor medication storage room also contained expired Banatrol Plus packets, a supplement used for diarrhea treatment. Four expired packets were found in the cart and seventeen expired packets were found in the storage room. LPN #1 was present during the observation of the expired supplement. The DON stated that expired medical supplies should be discarded and that Banatrol was a food item that should not have been kept in the medication cart.
Failure to Honor Resident's Advance Directive Due to Documentation Errors
Penalty
Summary
The facility failed to ensure that a resident's right to formulate and have their advance directive honored was upheld. Upon admission, the resident, who had a history of acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, pulmonary hypertension, COPD with acute exacerbation, and pneumonia, had a Colorado Medical Orders for Scope and Treatment (MOST) form completed and signed by the resident's representative and a nurse practitioner. This form clearly indicated the resident's wishes to receive CPR in the event of cardiac or respiratory arrest. However, the facility incorrectly transcribed the resident's code status as 'Do Not Resuscitate' (DNR) in the electronic medical record (EMR), care plan, medication administration record (MAR), and nurses' report sheet, which conflicted with the signed MOST form. When the resident was found unresponsive and without vital signs by a CNA and subsequently assessed by an LPN and an RN, staff did not initiate CPR or contact emergency medical services. The LPN and RN both relied on the information from the nursing report sheet, which incorrectly listed the resident as DNR, rather than referencing the MOST form or the EMR for the accurate code status. As a result, the resident's expressed wishes for resuscitation were not honored, and no resuscitative efforts were made prior to the physician pronouncing death. Interviews with staff confirmed that the nurses did not check the MOST form binder or the EMR to verify the resident's code status at the time of the incident. Instead, they relied on outdated or incorrect information from the report sheet. The facility's failure to ensure accurate and consistent documentation of the resident's advance directives directly led to the staff not attempting resuscitation, contrary to the resident's documented wishes.
Missed Admission Medications and Failure to Notify Physician
Penalty
Summary
The facility failed to ensure Resident #5 received prescribed medications as ordered on admission and failed to notify the physician when medications were not administered. Resident #5 was admitted with diagnoses including cellulitis of the right lower limb, a pressure ulcer of the right hip, diabetes, and respiratory failure. The resident was cognitively intact with a BIMS score of 15 out of 15 and required varying levels of assistance with activities of daily living. The physician’s admission orders included ceftriaxone IV for sepsis, along with multiple routine medications such as ferrous sulfate, Jardiance, allopurinol, bumetanide, potassium chloride, prednisone, sertraline, tamsulosin, apixaban, carvedilol, and gabapentin. The record showed that on the first day of admission, ceftriaxone, ferrous sulfate, Jardiance, allopurinol, bumetanide, potassium chloride, prednisone, sertraline, tamsulosin, apixaban, carvedilol, and gabapentin were not administered because they were documented as not available. Several of these medications were listed as continuously available at the facility and could have been administered as ordered. Nursing progress notes did not show that the physician was notified about the missed doses. Staff interviews indicated that nurses were expected to verify orders, check the automated dispensing system, contact the pharmacy, and notify the physician when medications were unavailable or delayed. The pharmacist later stated that all of Resident #5’s medications, including ceftriaxone, were delivered to the facility that afternoon, but the ceftriaxone was still not administered that day after receipt.
Failure in Anticoagulant Management and Change of Condition Response
Penalty
Summary
The facility failed to ensure that residents received treatment and care consistent with professional standards of practice, particularly in the management of anticoagulant therapy. This deficiency affected multiple residents, including one who was admitted with a history of long-term anticoagulant use. The facility did not document anticoagulant monitoring for this resident over a period of 13 days, and there was no care plan addressing the risks and monitoring expectations for anticoagulant therapy. Additionally, there was no consent documented for the use of the anticoagulant medication Eliquis. A significant change in the resident's condition was not properly managed. The resident was found with coffee-colored emesis and a dark bowel movement, indicative of a potential gastrointestinal bleed. Despite these symptoms, there was no documentation of a full assessment by the RN, and the resident was not sent to the hospital, contrary to the facility's expectations for such a condition. The resident's care plan was not updated to reflect a change in code status, and the MOST form indicating a DNR status could not be located. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and the decision-making process. The ADON, who was acting as the interim DON, was under the impression that the bleeding was not a new issue, based on reports from staff. However, the LPN and other staff indicated that the bleeding was a new occurrence. The facility's failure to properly assess, document, and respond to the resident's change in condition contributed to the resident's death, which was attributed to a presumed gastrointestinal bleed.
Removal Plan
- Resident-centered care plan was created for all residents who currently received anticoagulant medications.
- Orders for ongoing monitoring for anticoagulant medications were obtained from the providers on all residents who do not have orders.
- An in-service was completed by the DON/designee to all licensed nursing staff to ensure that the facility performs adequate physical assessments for change of conditions, recognize changes and how to accurately and timely communicate the assessment findings to the physician on call.
- An in-service was completed by the DON/designee to all licensed nursing staff to ensure that they analyze the situations for when to send residents to the hospital, with background information, assessments and recommendations with a timely, consistent and accurate process.
- Education will be provided to all nursing staff prior to the start of their shift.
- The DON or their designee will oversee the compliance with the resident-centered care plan and ensure continuous monitoring of anticoagulant therapy.
- Monitoring will follow a schedule: Daily, Weekly, Monthly, or until substantial compliance is achieved.
Failure in QAPI Program Leads to Resident's Death
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, which resulted in a serious deficiency. The QAPI committee did not identify and address a critical quality of care issue, specifically the failure to send a resident to the hospital when indicated. This oversight led to a situation of immediate jeopardy, resulting in the resident's death due to a gastrointestinal bleed. The facility's policy required the QAPI plan to identify high-risk areas and use relevant data to improve care, but this was not effectively executed. Interviews with staff revealed gaps in communication and awareness of the quality of care issues. The Medical Director, who regularly attended QAPI meetings, was unaware of the incident and other related care problems, such as anticoagulant monitoring and care planning. The Nursing Home Administrator, new to the facility, acknowledged the QAPI committee's monthly meetings but did not address the specific deficiency in a timely manner. The high turnover rate among staff and leadership was noted as a contributing factor to the lack of stability and continuity in addressing quality of care concerns.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of a resident, who was 79 years old and had been admitted with diagnoses including pneumonia, respiratory failure, muscle weakness, and atrial fibrillation. The resident, who had moderate cognitive impairments, expressed a preference for showers twice a week, which was documented in her care plan. However, the facility did not adhere to this schedule, as the resident only received showers on four out of eight scheduled opportunities over a period of several weeks. Interviews with staff revealed that the facility had a policy to accommodate resident preferences and document any refusals or missed showers. Despite this, the resident's preferences were not consistently met, and there was a lack of follow-up when showers were missed. The assistant director of nursing acknowledged the expectation for staff to offer showers later in the day if initially missed and to document any refusals, but this was not consistently practiced, leading to the deficiency in honoring the resident's choice.
Infection Control Deficiencies in PPE Use and Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Staff did not consistently identify residents on enhanced barrier precautions (EBP) due to the absence of appropriate signage outside residents' rooms. For instance, Resident #140, who had multiple wounds and a central intravenous line, did not have an EBP sign on his door on multiple occasions, leading to staff entering the room without donning the required personal protective equipment (PPE) such as gowns and gloves. This oversight was compounded by staff documentation errors, where the medication administration record (MAR) inaccurately indicated that EBP signage was in place. Additionally, the facility's staff failed to adhere to proper infection control procedures during medication administration. Resident #188, who was receiving intravenous medications through a PICC line, did not have an EBP sign on his door until several days into the survey. During this period, a registered nurse administered IV medications without wearing a gown, contrary to the facility's infection control policy. Interviews with staff revealed a lack of clarity and consistency in understanding the requirements for PPE use during high-contact care activities, particularly when dealing with indwelling lines. The facility also demonstrated lapses in hand hygiene and PPE use during routine care activities. An LPN was observed administering medications, including blood glucose checks and insulin injections, to multiple residents without performing hand hygiene or donning a gown, despite the presence of precautionary signage indicating the need for such measures. This failure to follow established infection control protocols was acknowledged by the Director of Nursing, who confirmed that gowns and gloves should have been worn during these procedures to prevent potential contamination and transmission of infectious agents.
Deficiency in Accurate and Timely MDS Assessment
Penalty
Summary
The facility failed to maintain accurate and timely minimum data set (MDS) assessments for a resident, leading to a deficiency. The resident, aged 68, was admitted with diagnoses including Parkinson's disease, psychotic disorder with hallucinations, major depressive disorder, and neuropathy. The resident was admitted on hospice care, but the admission assessment did not reflect this status. Additionally, the quarterly assessment was submitted late, beyond the required 92-day timeframe. The functional abilities section of both the admission and quarterly assessments was incomplete. Interviews with facility staff revealed misunderstandings and errors in the MDS assessment process. The nursing home administrator acknowledged that the MDS assessments should have included functional abilities and hospice care. The MDS coordinator admitted to submitting the quarterly assessment late and was under the impression that the functional abilities section should not be completed if the resident did not receive therapy. However, the resident's electronic medical record indicated that skilled services, including therapy, were being provided, contradicting the coordinator's understanding.
Inadequate Respiratory Care for Residents Using CPAP Machines
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required the use of CPAP machines. Specifically, the facility did not ensure that there were physician's orders in place for the use of CPAP machines for these residents, which should have included details such as the route of administration, frequency, oxygen supplementation, storage, and settings of the device. Additionally, there was no routine cleaning schedule implemented for the CPAP machines, and the manufacturer's guidelines for cleaning were not provided during the survey. Resident #12, who was moderately cognitively impaired and dependent on care for various activities, reported that his CPAP machine was not cleaned at the facility despite using it every night. A review of his medical records confirmed the absence of a physician's order for the CPAP machine and a lack of a care plan addressing its use and maintenance. Similarly, Resident #138, who had multiple diagnoses including chronic kidney disease and morbid obesity, reported that the facility used tap water instead of distilled water in her CPAP machine due to a shortage. Her medical records also lacked a physician's order for the CPAP machine and a comprehensive care plan. Interviews with facility staff, including the NHA, DON, and a rehabilitation aide, revealed that there was an expectation for residents to have physician's orders for CPAP machines, including cleaning instructions. However, this was not consistently implemented, as evidenced by the deficiencies found in the care of Residents #12 and #138. The staff acknowledged the importance of using distilled water and maintaining a cleaning schedule, but these practices were not followed, leading to the identified deficiencies.
Significant Medication Errors in Blood Pressure Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of blood pressure medications. The resident, who was under 65 years old and diagnosed with heart disease and high blood pressure, was prescribed Lisinopril and Carvedilol with specific parameters for holding the medication based on blood pressure and heart rate. However, the medication administration record revealed that these medications were administered on multiple occasions despite the resident's blood pressure and heart rate being below the physician-specified parameters. There were no progress notes explaining why the medications were given contrary to the orders. Interviews with staff, including an LPN and the nurse practitioner, confirmed that the medications should have been held when the resident's vital signs were below the specified parameters. The nurse practitioner emphasized the importance of these parameters for safety and noted that administering the medications under these conditions constituted a significant medication error. The director of nursing acknowledged that the medications should have been held and that the physician should have been notified of the error.
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Illustrative
What surveyors actually found near you
We read the 185 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greeley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Greeley | 0.8 mi | ★★★★★ | 0 | 0 |
| Grace Pointe Cont Care Sr Campus, Skilled Nursing | 1.6 mi | ★★★★★ | 4 | 0 |
| Westlake Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Broadview Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Fairacres Manor, Inc. | 2.6 mi | ★★★★★ | 0 | 0 |
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