Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 City Park Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Resident council grievances were not timely followed up on or documented with residents. Records showed concerns about food quality and resident preferences were noted, but the facility did not document follow-up with residents or discussion of the resolutions at the next council meetings. During interview, several residents said they did not feel the facility followed up on their concerns, and one resident said the response time was too long.
Infection control failures were observed during housekeeping and wound care. Two housekeepers cleaned resident rooms without proper hand hygiene, used disinfectant without allowing required dwell time, cleaned from dirty to clean areas, reused the same brush and mop head across multiple surfaces, and failed to disinfect high-touch items such as call lights and door handles. In a separate event, an IP performed wound care for a resident with a foot ulcer and heel pressure injury while wearing gloves only and not a gown, despite enhanced barrier precautions being indicated.
Failure to Promptly Resolve a Resident Grievance: A cognitively intact resident with COPD and dependence on supplemental O2 reported a missing portable O2 tank to the NHA and received no resolution or discussion of corrective action for months. No grievance form was found in the record, and the NHA acknowledged he knew about the issue but did not complete a grievance form when first informed.
A resident with chronic respiratory failure with hypoxia, CHF, CKD, OSA, anxiety, and an implanted cardiac defibrillator was observed removing her oxygen and going outside to smoke in her wheelchair. Her care plan identified a potential for injury related to smoking and called for smoking assessments as needed, but the facility did not complete another smoking evaluation after the initial assessment or after her return from a hospital stay. Records and staff interviews showed ongoing smoking, counseling about the health risks, and uncertainty about why the smoking evaluation was not triggered.
Dialysis care was not carried out as documented for two residents. One resident with ESRD, hemiplegia, and HTN did not have post-dialysis BP documented as ordered, and the order was not updated promptly when his dialysis days changed. Another resident with ESRD, DM2, and hepatitis C had a dialysis-center recommendation to limit fluids to 1 liter/day, but the facility did not obtain a physician order, update the care plan, or monitor fluid intake.
A facility failed to provide adequate outside ventilation in five of eight resident bathrooms because the exhaust fans were not working. During observation, toilet tissue would not stay in place at vents in multiple bathrooms, and none of those bathrooms had windows. The maintenance director said he was unaware of the broken vents and later identified a broken roof-mounted ventilation motor.
A resident with an ileostomy did not receive ostomy care according to physician orders and professional standards. The resident often changed her own appliance without formal training, and staff inconsistently followed care protocols, including not using dedicated equipment, not applying prescribed treatments, and failing to perform proper hand hygiene. The resident's skin was observed to be red and inflamed, and staff interviews confirmed lapses in following established procedures.
A resident with dementia and hemiplegia was physically abused by another resident with a history of behavioral disturbances, resulting in a wrist fracture. The incident occurred after one resident told the other to "shut up," prompting a physical response. Staff and care plans did not adequately address the known behavioral triggers and risks, leading to the altercation and injury.
Resident Council Grievances Not Timely Followed Up or Documented
Penalty
Summary
The facility failed to provide timely response, action, and rationale to residents involved in group grievances brought up during resident council meetings. The grievance policy stated that the facility would establish a grievance process to address resident concerns without fear of discrimination or reprisal and make prompt efforts to resolve grievances, including concerns voiced at resident and/or family council meetings. However, the resident council grievance records for 10/25/25, 11/19/25, and 12/17/25 documented concerns about hard-to-cut meat, ongoing food quality issues, and television and activity preferences, but did not document that the facility followed up with residents regarding the resolutions or discussed the resolutions at the next resident council meetings. During a group interview on 1/14/26, residents #7, #18, #26, #45, #60, and #68 were interviewed, and Resident #18, Resident #7, and Resident #60 stated they did not feel the facility followed up on their concerns. Resident #18 said the response time was too long. Staff interviews indicated CNA #5 was aware residents sometimes complained about food but did not typically complete grievance forms for those complaints. The NHA stated grievances were reviewed daily at the morning meeting and that department heads followed up on grievances, but also acknowledged the facility did not document resolution follow-up for the resident council grievances.
Infection Control Failures During Housekeeping and Wound Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment on two units. During housekeeping observations, Housekeeper #1 was seen cleaning a double occupancy room while wearing gloves but not performing hand hygiene before entering the room or after removing gloves. She sprayed disinfectant on surfaces such as the mirror, sink area, and toilet, then wiped them immediately instead of allowing the disinfectant to remain wet for the required dwell time. She also used the same brush to clean both the inside of the toilet bowl and the outside surfaces, and she used the same mop head to mop both sides of the room. High-touch areas such as call lights, door handles, light switches, and headboards were not disinfected and cleaned. Housekeeper #2 was also observed cleaning a double occupancy room without performing hand hygiene before donning gloves. She sprayed the toilet with disinfectant and wiped it immediately, removed a toilet riser and placed it in the middle of the resident's room, and used the same brush and rag to clean multiple toilet surfaces, including the inside and outside of the bowl, the underside of the seat, the rim, the top of the seat, and the basin. She did not disinfect the toilet brush before placing it back in the cart. She also failed to sweep the room before mopping, mopped one side of the room with the same mop pad used on the other side, and did not clean high-frequency touched areas. The report states she failed to follow dwell time for the disinfectants used and failed to clean from the cleanest to the dirtiest areas. In a separate observation, the infection preventionist entered a resident's room to perform wound care for a resident with a right heel pressure injury and a foot ulcer, but she wore gloves only and did not put on a gown. The resident stated he had an ulcer on the bottom of his foot. The infection preventionist later stated she forgot to put her gown on and acknowledged she should gown and glove for treatments requiring enhanced barrier precautions. The medical director confirmed the resident had a right heel pressure injury.
Failure to Promptly Resolve a Resident Grievance
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance for one resident. Resident #21, who was cognitively intact with a BIMS score of 14 out of 15 and had diagnoses including COPD, fibromyalgia, dependence on supplemental oxygen, depressive disorder, a cardiac pacemaker, and a history of TIA, reported that her portable oxygen tank had been missing for more than three months. She told the NHA about the missing tank and stated she did not receive any resolution or discussion about what action would be taken to address the issue. Record review found no grievance forms for the resident over the previous six months. During interview, RN #2 stated nursing staff were responsible for reporting grievances to supervisors and assisting residents with resolution, but she believed grievance forms were only for abuse incidents. The NHA stated staff were trained to handle grievances and that he had been informed about the missing oxygen tank several months earlier, but he did not complete a grievance form when he became aware of the issue and acknowledged that he should have done so immediately.
Failure to Reassess Smoking Safety for a Resident Using Oxygen
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for one resident who smoked and used oxygen. Resident #23 was cognitively intact with a BIMS score of 14 out of 15 and had diagnoses including chronic respiratory failure with hypoxia, congestive heart failure, anxiety, chronic kidney disease, obstructive sleep apnea, and an implanted cardiac defibrillator. Her smoking care plan, initiated and revised before the survey, identified a potential for injury related to smoking and included interventions to complete smoking assessments as needed, educate her on safe smoking practices, and explain the smoking policy. The resident’s smoking assessment was completed on 5/10/25, which documented that she smoked five times a day, used oxygen, safely lit and held smoking materials, and disposed of them appropriately. After that assessment, the facility did not complete additional smoking assessments until 1/14/26 during the survey, despite the care plan calling for assessments as needed. The record also showed that the resident returned from a hospital stay on 6/6/25, but no smoking evaluation was completed after that return, even though staff stated a smoking assessment would be done again after hospitalization. Survey observations on 1/14/26 showed the resident removing her oxygen cannula in her room, traveling to the first floor, and telling staff near the exit that she did not wear oxygen outside to smoke. She then exited the building with a cigarette and self-propelled her wheelchair away from the facility. Record review also showed multiple notes documenting ongoing smoking, including counseling that smoking was not advised, reports that she continued heavy cigarette smoking, and her request for help quitting and nicotine patches. Staff interviews confirmed that smoking evaluations were expected when residents smoked, changed smoking status, or returned from hospitalization, but the DON stated the resident’s smoking evaluation was not triggered and was unsure why.
Dialysis Care Not Followed as Ordered
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for two residents who required dialysis services. One resident had end stage renal disease, hemiplegia and hemiparesis affecting the right dominant side, and hypertension, and his care plan included obtaining blood pressure upon return from dialysis. Although his dialysis schedule changed to Monday, Wednesday, and Friday, the physician order for post-dialysis blood pressure monitoring was not updated to match those days until several months later. The resident's electronic medical record did not show that his blood pressure had been obtained or documented after dialysis, even though staff stated that post-dialysis blood pressure was a standing expectation and should have been completed. A second resident had end stage renal disease, type 2 diabetes mellitus without complications, and chronic viral hepatitis C, and received dialysis on Monday, Wednesday, and Friday. The dialysis communication form from the dialysis center included a recommendation to limit fluids to one liter per day. The resident stated that nursing staff had talked to him about limiting fluids, but he was unsure whether he was receiving the correct amount. The resident's care plan did not include monitoring fluid intake, and the record did not show that the facility obtained a physician order or updated the care plan to reflect the dialysis center's fluid restriction recommendation. The record also did not show that the facility monitored the resident's fluid intake after receiving the dialysis communication form. Staff interviews indicated that the dialysis recommendation was placed in the chart, but the nurse did not contact the dialysis center to clarify the restriction, and the DON stated that vague dialysis instructions should have been verified and then communicated through the physician and interdisciplinary process. The NHA stated the facility discussed the recommendation with the resident, but the documentation reviewed showed no physician order, no care plan update, and no monitoring of intake.
Nonfunctioning Bathroom Exhaust Fans
Penalty
Summary
The facility failed to provide adequate outside ventilation in five of eight resident bathrooms because the exhaust fans were not functioning. During an observation with the maintenance director, a small square of single-ply toilet paper was placed against the vent in room [ROOM NUMBER], #318, #416, #510, and #511, and the tissue did not remain in place, indicating the fans were not working at that time. None of the bathrooms had windows, and the vents were not functioning. The facility’s Safe and Homelike Environment policy stated that the facility would provide a safe, clean, comfortable, and homelike environment, including resident bathrooms. In interviews, the maintenance director said he monitored vent motor operation monthly and fixed concerns as they arose, but he was not aware of the broken vents in the resident bathrooms. He later stated that one of the roof-mounted ventilation motors was broken and that parts had been ordered for replacement.
Failure to Provide Ostomy Care per Physician Orders and Professional Standards
Penalty
Summary
A deficiency occurred when a resident with an ileostomy did not receive ostomy care in accordance with physician's orders and accepted professional standards. The resident, who had diagnoses including morbid obesity, peripheral vascular disease, ileostomy, dementia, and cognitive deficit, required supervision or assistance with ostomy management. The resident reported that she often changed her own ostomy appliance due to staff being busy and had not received formal training from the nursing staff. She also stated that the facility frequently ran out of her prescribed nystatin powder, and that staff used different types of appliances and methods for her ostomy care, depending on what supplies were available. Direct observation revealed that a registered nurse performed ostomy care without reviewing the resident's treatment orders beforehand. The nurse failed to follow several critical steps, including not using dedicated clean scissors, not cleaning the scissors before use, not applying skin prep or nystatin powder as ordered, and not using wound cleanser to clean the stoma area. The nurse also did not change gloves between dirty and clean tasks and did not wash hands with soap and water after the procedure. The resident's skin around the stoma was observed to be red, inflamed, and painful, with stool leaking from beneath the appliance. Interviews with staff confirmed that nurses were expected to check physician's orders before treatments and use designated equipment for wound and ostomy care. Staff also indicated that residents should not perform their own wound or ostomy care without a safety assessment, and that proper hand hygiene and glove changes were required to prevent infection. The assistant director of nursing and other staff acknowledged that the resident insisted on changing her own appliance, but documentation of education provided to the resident was lacking. The facility's failure to ensure consistent, ordered, and hygienic ostomy care led to the deficiency.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia and right-sided hemiplegia was not protected from physical abuse by another resident with a history of behavioral disturbances, including agitation and aggression. The incident took place in a common area, where the first resident told the second resident to "shut up" after the latter was loudly talking to himself. In response, the second resident stood up and pushed the first resident, causing her to fall and sustain a left wrist fracture. Multiple staff members witnessed or heard the altercation, confirming the sequence of events. The resident who committed the abuse had a documented history of behavioral issues, including yelling at the television and other residents, and had previously exhibited escalating agitation and threatening behavior. His care plans included interventions for managing agitation and physical behaviors, but did not specify actions for guiding other residents away from him when he became agitated or physically aggressive. Staff interviews indicated that the resident was known to be triggered by being told to "shut up," and that staff had previously redirected him or advised other residents not to use such language toward him. Despite the known behavioral risks and triggers associated with the second resident, the facility failed to implement sufficient measures to prevent the altercation. The care plan lacked specific interventions to protect other residents from potential physical aggression, and staff did not intervene before the incident occurred. As a result, the first resident was not safeguarded from abuse and suffered a significant injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 499 citations issued within 25 miles in the last 12 months — including the 7 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarwood Health Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Health Center At Franklin Park | 1.1 mi | ★★★★★ | 14 | 0 |
| Denver North Care Center | 1.2 mi | ★★★★★ | 17 | 0 |
| Uptown Care Center | 1.6 mi | ★★★★★ | 11 | 0 |
| City Scape Rehabilitation & Care Center Llc | 1.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for City Park Healthcare And Rehabilitation Center.
100% money-back within 48 hours.
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.