Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Denver North Care Center during CMS and state inspections, most recent first.
Hand hygiene was not performed appropriately during dishwashing, as a dietary aide handled dirty dishes, moved to the clean dish area, and unloaded clean dishes without washing or sanitizing hands between tasks. Surveyors also found a food prep table area with a bent metal piece, visible crumbs, a brown sticky substance, and a foul odor beneath the surface. Staff interviews showed the area had been used for meal prep and had not been maintained in a clean, sanitary condition.
Expired medications and biologicals were found stored in multiple medication rooms, medication carts, and vaccination refrigerators. Items included expired suppositories, vaccines, test cards, control solutions, vitamins, syringes, and other loose or unidentified pills. An LPN and the DON stated that nurses, the unit manager, and central supply staff were responsible for checking for expired medications and cleaning medication carts.
A facility failed to maintain infection control practices during housekeeping, wound care, and meal service. A housekeeper cleaned a resident room without changing cloths appropriately, did not maintain disinfectant contact time, used soiled gloves across surfaces, and failed to disinfect high-touch items such as call lights and bed controls. During wound care, staff did not use all required PPE, placed supplies on the resident’s bed, and did not perform hand hygiene before, during, or after care. Expired hand sanitizer was also found in medication areas, and staff failed to perform hand hygiene after handling a resident’s cup, dirty dishes, and personal items, and before the resident ate.
Resident council grievances were not effectively addressed or communicated to residents. Alert and oriented residents reported that concerns about evening shift noise, late meals, staff availability during meals, and staff entering rooms without knocking were repeatedly raised in council but not resolved or shared back with the group. Meeting minutes and grievance forms showed staff education and other resolutions, but the record did not document that the council was told about the outcomes or that the concerns were fully reviewed and closed.
The facility failed to give timely NOMNCs to two residents when Medicare Part A skilled therapy ended. One resident had hemiplegia, hemiparesis, and mild cognitive impairment, and another had dementia with severe cognitive impairment and was receiving PT. In both cases, the NOMNC was issued after or on the same day covered services ended, rather than before the end of coverage.
A resident with dementia, depression, and anxiety was given sertraline and escalating doses of olanzapine, but the chart did not show documented behavior increases or worsening condition to justify the changes. The care plans and behavior monitoring were not updated to match the dose increases, the TAR had no documented behaviors, and psychiatrist notes repeatedly described the resident as calm, cooperative, and at baseline. Staff interviews also described limited behavioral concerns, and the facility could not provide documentation supporting the psychotropic increases.
PASRR Level II Recommendation Not Incorporated Into Care Plan: A resident with borderline personality disorder and major depressive disorder had a PASRR Level II determination requiring a neurocognitive evaluation, but the recommendation was not added to the care plan and no order, progress note, or documentation showed the evaluation was scheduled or completed. Staff interviews confirmed social services was responsible for managing PASRR recommendations, yet no documentation was found showing communication with the State Mental Health Agency about the unmet recommendation.
A resident with severe cognitive impairment and dementia-related diagnoses was not assisted in obtaining a designated representative to make care decisions, and consent for a transfer pole and psychoactive meds was not properly established. Records showed a guardianship referral was made but not followed up, the resident could not understand or identify his meds, and staff said he was unable to sign consents for himself.
A resident with severe cognitive impairment and total dependence on staff did not receive drinks at bedside or during dinner, despite care plans calling for encouragement of hydration and staff stating fluids should be offered at meals and throughout the day. Observations showed no beverages in the room or at the table, and staff did not offer drinks while the resident was eating or when he returned to his room.
A resident with a history of mental health issues was involved in two altercations with other residents, leading to physical and verbal abuse. The facility failed to update care plans promptly and ensure consistent monitoring, contributing to the deficiency in protecting residents from abuse.
A resident with a traumatic brain injury and mood disorder exhibited aggressive behaviors, but the facility failed to update care plans with person-centered interventions after multiple altercations. Despite having care plans, the facility did not effectively implement or document interventions, and there was no evidence of psychological services in the resident's records. Efforts to find alternative placement were also inadequately documented.
Hand Hygiene and Kitchen Sanitation Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service standards in the main kitchen. During dishwashing, a dietary aide loaded dirty dishes into the dishwasher with bare hands, then moved to the clean dish area and unloaded clean dishes without performing hand hygiene, and then returned to the dirty dish side to push the rack into the dishwasher before again handling clean dishes without washing or sanitizing hands. The dietary aide stated he would sanitize his hands or rinse them when moving from dirty to clean dishes, while the dietary manager stated staff were expected to clean their hands with soap and water before putting away clean dishes. The facility also failed to ensure the food preparation area was clean and sanitary. Surveyors observed a curved metal piece on a small food preparation table next to the main steam table and beneath the microwave shelf, with visible crumbs in the bent area and gaps where the metal did not lie flat. When the metal piece was pried up, piles of crumbs were found in the hole, along with a brown sticky substance around the edge of the metal piece and the hole, and a foul odor was present. Staff interviews confirmed the area had not been maintained in a sanitary condition. A cook stated the table had previously held a juice machine and that liquids drained through that area, and said she normally cleaned it two to three times a day but had just returned from vacation. The dietary manager said she was working on a cleaning schedule and would add cleaning that part of the table to it, while the nursing home administrator said she was not aware of the sticky substance near the table. The registered dietitian and dietary manager also stated the table was used for small meal preparation and getting ready to serve meals.
Expired Medications Found in Medication Rooms, Carts, and Refrigerators
Penalty
Summary
Expired drugs and biologicals were found stored in multiple medication areas, including two medication rooms, two medication carts, and two vaccination refrigerators. In the first-floor medication room, the medication refrigerator contained six acetaminophen 650 mg suppositories expired in October 2025 and four vials of Prevnar 20, with three expired in January 2025 and one expired in March 2025. In the first-floor medication cart, five loose pills were found in the drawers, including two Busparone tablets, two Atrovastin tablets, and one Baclofen tablet. In the second-floor medication cart, eight tablets of Mucus Relief DM expired in November 2025 were found along with six unidentified loose pills at the bottom of the drawer. In the second-floor medication room, expired items included two Hemacolt Developers expired in January 2025, eighty Hemacolt test cards expired in October 2025, two COVID home tests expired 11/1/24, three Assure control solutions expired in October 2025, March 2025, and August 2025, two open bottles of Vitamin C 500 mg expired in November 2025, thirty soft gels of CoQ10 100 mg expired in August 2025, two bottles of Ocular Vitamin expired in November 2025, two hundred fifty tablets of folic acid 400 mcg expired in September 2025, forty-five tuberculin syringes expired in October 2025, and one bottle of eye itch relief expired in November 2025. The second-floor medication refrigerator also contained four Ativan suppositories expired 12/14/25. Staff interviews indicated that nurses, the unit manager, central supply staff, the DON, and the NHA were responsible for checking and removing expired medications, and that each nurse on shift was responsible for cleaning medication carts.
Infection Control Failures During Housekeeping, Wound Care, Hand Hygiene, and Meal Service
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. During observation of housekeeping practices in a double-occupancy resident room, a housekeeper cleaned surfaces with a dry cloth sprayed with disinfectant, then used the same cloth across multiple areas without changing it after cleaning the sink bowl. The housekeeper also did not keep the disinfectant wet on surfaces for the required contact time, did not change cloths between the two sides of the room, and used the same cloth to clean the toilet and then other bathroom and room surfaces. The housekeeper failed to change gloves after cleaning the bathroom, touched the cleaning cart and other room surfaces with soiled gloves, and did not disinfect high-touch items such as call lights, bed controls, and light switches during the cleaning process. The report also documented failures during wound care. A resident with a wound was observed during weekly wound rounds and later during wound care in the resident room. Staff entered the room and completed wound care without applying all PPE required for enhanced barrier precautions, and there was no PPE or precaution sign outside the room. During another wound care observation, staff placed wound care supplies directly on the resident’s bed, removed the old dressing, changed gloves, and then cleaned and dressed the wound without performing hand hygiene before, during, or after the procedure. The infection preventionist stated she was unaware PPE needed to be worn during dressing changes, and an LPN stated PPE was not needed because the wound was not draining and there was no risk of splash back. The facility also had expired hand sanitizer in use areas. In the medication room and on a medication cart, multiple bottles of hand sanitizer were observed with expiration dates ranging from March 2023 to 2022, including one bottle with an illegible expiration month. In addition, during meal service, staff failed to perform hand hygiene after touching a resident’s used cup, shaking the resident’s hand, handling dirty dishes, and moving between tasks. Staff also failed to sanitize a resident’s hands before eating and did not sanitize the resident’s basketball after it had been handled and placed on the floor. Interviews with nursing staff and the DON confirmed expectations for hand hygiene before and after meals and after contact with residents or soiled items.
Resident Council Grievances Not Resolved or Shared
Penalty
Summary
The facility failed to provide responses, actions, and rationale to residents involved in group grievances brought up during resident council meetings. Four alert and oriented residents who regularly attended resident council reported that the meetings were not productive and that concerns raised in council were not followed up on or resolved. They stated that staff noise on the evening shift woke residents, that there was a lack of communication from administration about what was done to resolve grievances, and that resolutions were not shared with the resident council president or the council itself. One resident also reported that second-floor residents who did not go to the dining room were served room trays one to one and a half hours later than other residents, and that this concern had been reported to staff. Record review showed repeated resident council grievances about evening shift noise, late meals, nurses not being available during meals, difficulty finding staff, and staff entering rooms without knocking. The meeting minutes documented these concerns across multiple months, but there was no documentation that the earlier grievances had been reviewed or resolved, and no documentation that resolutions were shared with the resident council. Grievance forms showed resolutions such as staff education on softer shift-change reports, knocking before entering rooms, and assisting in the dining room during evening meals, but the forms did not document when the resolutions were provided to or approved by the resident council. No grievance form was found for the late meal concern raised by residents.
Untimely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide timely written Medicare non-coverage notices to two residents and their representatives when Medicare-covered skilled services ended. For Resident #14, who had hemiplegia, hemiparesis, and limited activities due to disability, the record showed mild cognitive impairment with a BIMS score of 12. Speech therapy began on 8/4/25, and a therapy note on 10/7/25 documented discussion of goals and discharge planning. The SNF Beneficiary Protection Notification Review showed the last covered Medicare Part A skilled service was 10/17/25, but the NOMNC was not signed until 10/23/25, after the Medicare-covered services had already ended. For Resident #27, who had chronic embolism and thrombosis of the right lower extremity and dementia, the 11/12/25 MDS documented severe cognitive impairment and ongoing physical therapy services. A progress note on 11/13/25 stated therapy staff called the resident's representative and informed her the resident had been discharged from therapy, and verbal consent for the notice of noncoverage was obtained. The SNF Beneficiary Protection Notification Review showed the last covered Medicare Part A skilled service was 11/13/25, and the NOMNC was signed the same day, rather than before the end of covered services. Staff interviews indicated the health information manager and director of rehabilitation handled NOMNOCs and believed notices were issued several days before discharge from therapy. The DOR stated Resident #27's discharge date was 11/13/25 and acknowledged missing the date for issuing the notice. The DOR and NHA also stated the facility had staffing and role-coverage issues related to rehabilitation leadership during the period when the notices were handled.
Unjustified psychotropic medication increases without documented behavior changes
Penalty
Summary
The facility failed to ensure Resident #24 was free from unnecessary psychotropic medication use and was receiving the least restrictive approach for his needs. Resident #24 had diagnoses including anxiety, major depressive disorder, and unspecified dementia, and the MDS showed severe cognitive impairment with behaviors of delusions, verbal aggression, and wandering. The resident was unable to identify his medications or the day, year, or facility type during interview. The record showed sertraline was ordered for hypersexual behaviors, and olanzapine was ordered for dementia with agitation and later increased twice. However, the antipsychotic care plan and behavior monitoring orders were not revised to reflect the medication increases or to document an increase in behaviors or worsening condition that would justify those increases. The antidepressant care plan also did not include the physician’s indication for use. Review of the EMR showed psychiatrist notes repeatedly described the resident as calm, cooperative, psychiatrically stable, and at baseline, with no hallucinations, delusions, psychosis, mania, or acute behavioral concerns. The chart also contained pharmacist recommendations to decrease olanzapine, but the physician notes did not document agreement or disagreement with the recommendations in a way that showed a rationale tied to resident behaviors. The TAR contained no documented behaviors, and CNA behavior notes reflected limited behaviors such as refusing care or self-neglect without showing that the interventions were effective. Staff interviews described the resident as generally agreeable and kind, with no consistent reports of physical aggression, hallucinations, or delusions, and the facility was unable to provide documentation showing increased behaviors from baseline that justified the psychotropic medication increases.
PASRR Level II Recommendation Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to incorporate recommendations from the PASRR Level II determination and evaluation for one resident with serious mental illness or a related condition. Resident #39 was admitted with diagnoses including borderline personality disorder and major depressive disorder, and the resident’s MDS indicated cognitive intactness with a BIMS score of 15 out of 15 and behaviors of delusions. The resident’s PASRR Level II evaluation, provided to the facility, stated that the resident had been evaluated for mental illness due to major depressive disorder and was to receive a neurocognitive evaluation. The resident’s mood and behavior care plan identified the resident as having a Level II PASRR due to major depressive disorder and borderline personality disorder, but it did not include the PASRR recommendation for a neurocognitive evaluation. Review of the CPO and progress notes did not reveal any order or documentation showing that the neurocognitive evaluation had been scheduled or completed, and there were no PASRR progress notes documenting communication with the State Mental Health Agency about any delay or inability to follow the recommendation. During interview, the SSD stated social services was responsible for managing PASRR recommendations, and the NHA stated that if PASRR recommendations were not followed, a progress note would be made and the issue would be included in the care plan.
Failure to Secure Representative and Valid Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide medically related social services for one resident with severe cognitive impairment and diagnoses of anxiety, major depressive disorder, and unspecified dementia. Resident #24 had a BIMS score of 5 out of 15 and was documented as unable to determine the day, year, or type of facility he lived in during interview. He also stated he was not taking psychiatric medications and could not identify his medications, and he said he had never consented to the transfer pole in his room and could not explain its risks. Record review showed the resident’s care plan addressed antipsychotic use for dementia-related behaviors, but it did not include documentation about the transfer pole or the cognitive impairments requiring a guardian referral. The EMR contained a guardianship referral dated 3/24/24 because the resident was unable to make his own decisions due to diminished cognition, but there was no documentation that the referral had been followed up. A psychopharmacology meeting note stated the resident needed a guardian, and psychiatrist notes described him as unable to participate meaningfully in assessment due to cognitive deficits, with severe deficits in memory and thought production. The record also showed informed consent forms for the transfer pole that did not document consent by the resident or a representative, or documentation that the risks, benefits, and potential negative outcomes had been explained. Informed consent forms for psychoactive medication use showed the resident signed for olanzapine increases, but the resident was not aware he was on psychotropic medications and had severe cognitive impairments. Staff interviews indicated the resident was unable to make his own decisions or sign consents, had no friends or family to decide on his behalf, and the medical director was making decisions for him, while the social services director stated it was social services’ job to initiate and follow up on guardianship referrals.
Failure to Provide Fluids to a Dependent Resident
Penalty
Summary
The facility failed to ensure that Resident #11 received drinks consistent with his needs and preferences and sufficient to maintain hydration. Resident #11 was admitted with diagnoses including epilepsy, hypothyroidism, hyperlipidemia, and unspecified intellectual disabilities. His MDS indicated he was rarely or never understood, had severe cognitive impairment, and was dependent on staff for all ADLs. His care plans identified him as at risk for skin integrity issues and malnutrition, with interventions to encourage nutrition and hydration and to encourage him to eat food and drink fluids. During a continuous observation, Resident #11 was seen in his bed and later in the dining room without any water or other beverages at his bedside or table. Staff did not enter his room to offer him a beverage during the observation period, and when he was assisted to dinner, he did not have any drinks. He received his dinner without any beverages, staff did not offer or provide drinks while he was eating finger foods, and when he handed his plate to a nurse, he was not offered any drinks. When he was later assisted back to his room, there were still no beverages present. The resident representative said she never saw drinks in his room or at his bedside. A CNA stated residents were usually offered water at meals and every two hours, but Resident #11 was not offered drinks during the observation. An LPN stated Resident #11 had drinks at his bedside, which was not observed. The RD and regional dietary consultant stated residents should receive at least eight ounces of liquid at every meal and that fluids should be offered frequently. The DON and NHA stated staff should offer fluids during meals and outside of meals, and the DON said staff needed to be better with rounding with fluids on dependent residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to physical and verbal altercations. Resident #7, who has a history of traumatic brain injury, schizoaffective disorder, and other mental health issues, was involved in two separate incidents of aggression. In the first incident, Resident #7 physically assaulted Resident #9 after being called 'crazy,' resulting in a physical fight where both residents sustained injuries. The facility's investigation revealed that Resident #7 was placed on one-to-one supervision, but the behavior care plan was not updated until six days after the incident. In a second incident, Resident #7 pushed Resident #6 after a verbal exchange in the dining room. Despite the altercation, the facility did not update Resident #7's care plans with new interventions following this incident. The facility's investigation noted that Resident #7 was placed on 15-minute checks, but documentation of these checks was incomplete, and the facility failed to perform frequent checks during the 72-hour alert monitoring timeframe. Staff interviews indicated that while some de-escalation training was provided, it was not mandatory, and there were inconsistencies in how interventions were communicated and documented. The facility's failure to promptly update care plans and ensure consistent monitoring and documentation contributed to the deficiency in protecting residents from abuse.
Failure to Provide Adequate Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a traumatic brain injury, mood disorder, and mild cognitive impairment. The resident, who was cognitively intact, exhibited behaviors of physical and verbal aggression towards others. Despite having care plans in place, the facility did not update these plans with person-centered interventions after multiple incidents of resident-to-resident altercations. The care plans included interventions such as behavior monitoring, positive reinforcement, and medication management, but these were not effectively implemented or updated to address the resident's escalating behaviors. The facility's documentation and communication regarding the resident's behaviors and interventions were inadequate. Staff interviews revealed that while some interventions were attempted, such as redirection and speaking in a calm voice, these were not consistently documented in the resident's care plan or electronic medical record. The facility's psychoactive pharmacological meetings did not document reviews of the resident's behaviors or the effectiveness of interventions. Additionally, there was no evidence of psychological or psychiatric provider notes in the resident's records, despite claims that the resident was receiving such services. The facility also failed to make documented efforts to find alternative placement for the resident, who expressed a desire to move to a facility specializing in brain injuries. Although the social services director claimed to have sent out referrals to other facilities, there was no evidence of these efforts in the resident's electronic medical record. The facility's inaction and lack of documentation contributed to the deficiency in providing appropriate behavioral health care and services to the resident.
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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) |
|---|---|---|---|---|
| Health Center At Franklin Park | 0.6 mi | ★★★★★ | 14 | 0 |
| Uptown Care Center | 0.6 mi | ★★★★★ | 11 | 0 |
| Briarwood Health Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| City Park Healthcare And Rehabilitation Center | 1.2 mi | ★★★★★ | 9 | 0 |
| Juniper Village - The Spearly Center | 2.2 mi | — | 5 | 0 |
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