Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center At Lowry, Llc during CMS and state inspections, most recent first.
Improper Hand Hygiene and Glove Use During Meal Service: During meal service, a cook and the DM repeatedly handled food, clean dishware, utensils, and high-touch surfaces with the same gloves without changing them or performing hand hygiene. Staff were observed plating food, retrieving items from the refrigerator, and touching the eating surfaces of plates and sandwiches with gloved hands, while interviews confirmed they knew gloves should be changed after touching surfaces and before handling food.
A resident with multiple chronic conditions and intact cognition was found with a medication cup containing gabapentin and cyclobenzaprine left on the lunch tray cover/bedside area instead of being directly administered. An LPN later gave the meds more than an hour past the scheduled time, and both the LPN and DON stated it was not appropriate to leave medications with the resident without observing ingestion.
Improper medication storage and labeling were found in two medication carts. Unopened-date inhalers, eye drops, and PPD were left without open dates, PPD was stored in the cart instead of the refrigerator, an unlabeled medication cup contained softgel tablets, and loose pills were found in cart drawers. RNs and the DON acknowledged that medications should be dated when opened and that unlabeled or loose medications should not be left in the carts.
Four residents did not receive care in accordance with professional standards, including missed or undocumented administration of prescribed medication, failure to follow physician orders for wound care, and provision of wound treatments without physician authorization. Staff did not consistently enter or follow physician orders in the EMR, resulting in gaps in care and documentation.
A resident with a history of stroke and other chronic conditions experienced a brief episode of slurred speech, which was assessed and documented by nursing staff but not reported to the physician as required by facility policy. Staff interviews confirmed that the physician was only notified after a subsequent episode, resulting in delayed medical intervention.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
The facility failed to distribute food in a sanitary manner in the main kitchen during meal service because employees did not perform hand hygiene appropriately and repeatedly handled food with the same gloves after touching multiple surfaces. During a continuous observation on 3/31/26, cook #1 wore gloves while touching countertops, the refrigerator handle, utensils, the sneeze guard, and clean dishware, including the eating surfaces of plates and bowls, and continued plating bread, carrots, and other food without changing gloves or performing hand hygiene. He also left the service area and returned to food handling with the same gloves. During a continuous observation on 4/1/26, the dietary manager put on gloves, handled clean plates, scooped lettuce, added toppings, placed rolls on plates, left the service area to retrieve more plates, and touched the eating surfaces of the plates without changing gloves. Cook #2 washed his hands and donned gloves, then left the service area to retrieve wrapped sandwiches, unwrapped them, stabilized them with gloved hands while cutting them, and plated them. He later handled cooked chicken, cut it, and scooped it up with gloved hands for plating, then repeated similar actions after changing gloves. The dietary manager and cook #2 both stated that gloves should be changed when surfaces were touched and before handling food, and the dietary manager said staff should use utensils when plating food and not their hands.
Medication Left at Bedside and Given Late
Penalty
Summary
The facility failed to ensure Resident #8’s medications were administered in a timely manner and were not left at the resident’s bedside. Resident #8 was admitted with diagnoses including post-surgical aftercare following lumbar surgery, lumbar radiculopathy, multiple sclerosis, difficulty walking, pulmonary embolism, hypertension, long-term anticoagulant use, and major depressive disorder. The resident’s MDS showed he was cognitively intact with a BIMS score of 13 out of 15 and required partial assistance with ADLs and moderate assistance with ambulation, using a walker and wheelchair. On 3/30/26, a medication cup containing two tablets was observed sitting on the cover of Resident #8’s lunch tray at 2:15 p.m. and was still there at 2:43 p.m. At 2:45 p.m., LPN #3 entered the room and administered the two tablets, which were identified as gabapentin 600 mg and cyclobenzaprine 10 mg, both ordered for 12:00 p.m. administration. The medications were given more than one hour after the allowed administration time. LPN #3 stated he had left the medications on the bedside table and exited the room, and the DON stated it was not appropriate to leave medications with a resident and not observe the resident taking them.
Improper Medication Storage and Labeling in Medication Carts
Penalty
Summary
Drugs and biologicals were not properly stored, secured, and labeled in accordance with accepted professional principles on two medication carts. On the second floor medication cart A, a bottle of Xalatan eye drops was found without an open date, a vial of tuberculin PPD was not dated when opened and was being stored in the medication cart instead of the refrigerator, and a Spiriva inhaler was not dated when opened. A loose pill was also found in the bottom of the second drawer of the cart, and a medication cup in the top drawer contained seven burgundy softgel tablets without a resident name or medication label. On the third floor medication cart C, two Albuterol inhalers were not dated when opened, one Spiriva inhaler was not dated when opened, and one Arnuity Ellipta inhaler was not dated when opened. Seven loose pills were also found in the bottom of the second drawer of that cart. The report identified the loose pills on the second floor cart as Senna Plus, and on the third floor cart RN #4 identified two as acetaminophen and one as omeprazole, while the remaining four were unknown. Staff interviews confirmed that nurses were responsible for cleaning the medication carts on their shifts. RN #3 stated that medications should have open dates to avoid giving expired medication and said the unlabeled softgels in the medication cup were Preservision Eye Supplement tablets that had been poured from another cart’s over-the-counter bottle. RN #4 stated that loose medications could fall to the floor and be taken by a resident and that medications should always have an open date label. The DON stated that there should not be any medications in a medicine cup without a label in the medication cart and that medications should be marked with an open date to prevent giving an expired medication.
Failure to Follow Physician Orders and Document Wound Care and Medication Administration
Penalty
Summary
The facility failed to ensure that services provided to four out of five sampled residents met professional standards of quality, specifically in the areas of medication administration and wound care. For one resident, there was a physician's order for miconazole powder to be applied daily to the groin, but the medication was not documented as administered for several days, and there was no documentation explaining the omission. The wound care nurse admitted to not entering the physician's order into the electronic medical record (EMR) in a timely manner, which prevented floor nurses from administering the medication as prescribed. Another resident had an active physician's order for daily wound treatment and dressing changes to abrasions on the right hand, but the treatment was not documented as provided on two occasions. Additionally, the order was only updated after the issue was identified during the survey. The resident's care plan required dressing changes and skin treatment per physician's orders, but the documentation did not reflect consistent adherence to these orders. For two other residents, wound care treatments were provided without physician's orders. One resident received wound care to both great toes, and another received wound care to both legs, before the appropriate orders were entered into the EMR. Staff interviews confirmed that wound care was performed and documented in progress notes or paper logs, but not supported by active physician's orders in the EMR at the time of treatment. The director of nursing confirmed that all physician's orders should be entered into the EMR to ensure proper administration and documentation of care.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician when there was a significant change in the resident's condition, specifically when the resident experienced an episode of slurred speech. On the morning of 10/18/25, a nurse documented that the resident had a brief episode of slurred speech during assessment, which resolved with the resident returning to baseline. Vital signs were within normal limits, and no facial droop or extremity weakness was observed. However, there was no documentation that the physician was notified of this episode, despite facility policy and professional guidelines requiring immediate physician notification for new or unexpected findings such as slurred speech. The resident had a medical history including cerebral infarction, type 2 diabetes mellitus, and hypertension, and was cognitively intact according to recent assessments. Staff interviews revealed that the nurse who assessed the resident on 10/18/25 notified the ADON of the change in condition, but did not notify the physician. The ADON stated that she instructed the nurse to notify the physician, but this was not documented, and the DON confirmed that physician notification should have occurred. The deficiency was further highlighted when, four days later, the resident experienced another episode of slurred speech, at which point the physician was notified and the resident was transferred to the hospital. Facility records and staff interviews confirmed that the physician was not notified after the initial episode of slurred speech, and there was no documentation to support that the resident's intermittent slurred speech was considered baseline. The facility's policy required physician notification for such changes, and all interviewed staff agreed that this should have occurred. The lack of physician notification after the initial episode constituted a failure to follow both professional standards and facility policy regarding change in condition reporting.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
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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.
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Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lowry Hills Care And Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| Highland Park Rehabilitation & Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Hilltop Park Post Acute | 1.2 mi | ★★★★★ | 1 | 0 |
| Berkley Manor Care Center | 1.6 mi | ★★★★★ | 23 | 0 |
| Crestmoor Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.