Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkview Care Center during CMS and state inspections, most recent first.
An LPN provided wound care for a resident on EBP without donning a gown. Housekeeping staff cleaned resident toilets out of order and did not finish cleaning the toilet bowl in a sanitary manner. An RN failed to maintain sterility during trach suctioning and dressing care, and a CNA alternated meal assistance between two dependent residents without hand hygiene between residents.
Expired and discontinued meds were found in a medication cart and expired IV antibiotics were stored in the med room. An LPN, RN, and ADON confirmed the meds should have been removed, including gabapentin for a resident whose order had been discontinued and oxycodone for a resident who had already been discharged.
Food service failed to keep resident meals palatable in taste, texture, and temperature. Several residents reported cold room trays, bland or repetitive food, and missing requested items. Surveyors observed room tray service using an open, uninsulated cart and found a test tray with chewy, overcooked, and unseasoned items. During meal service, multiple steam table items fell below the safe hot holding temperature, and staff noted uneven heating, no plate warmer, and delayed room tray delivery.
The facility failed to follow professional standards for three residents. An RN suctioned a resident’s trach and then used the same tubing to suction the mouth instead of a separate Yankauer. For another resident receiving G-tube care, an RN flushed the tube while the resident was lying flat rather than with the HOB elevated. The facility also did not develop a specific care plan for a resident’s insomnia and did not consistently document ordered sleep hours while Trazodone was being adjusted.
A resident with legal blindness, diabetes, ESRD, and cognitive intactness sustained a second-degree abdominal burn after hot noodles spilled on him. The resident said he had been eating ramen noodles prepared by staff when the cup tipped and spilled, and survey observations later found him eating while lying in bed with the tray table over him and limited ability to position himself safely. Records and staff interviews showed the blister was not initially recognized by the CNA, and the resident’s burn was later treated as a wound.
Medication error rate exceeded the allowed threshold after surveyors observed an RN make two medication administration errors for a resident. The RN gave only one glipizide 10 mg tablet instead of the ordered two tablets and administered two drops of refresh tears to each eye instead of one drop. Record review confirmed the orders, and the RN stated he did not thoroughly review them before administration.
A deficiency occurred when staff did not promptly and thoroughly investigate an alleged sexual abuse incident between two cognitively impaired residents. A CNA heard a resident yelling and found a male resident standing over her bed with his hands on her chest and abdomen over her clothing and bedding, but the abuse investigation was not initiated immediately and the event was not initially treated as sexual abuse. The alleged victim and alleged perpetrator were interviewed many hours later, by which time neither could recall the incident. Video review showed the male resident entering and exiting the room but did not establish how long he was inside before staff intervened. Witness statements lacked detail about the nature of the touching, the residents’ demeanor, and what the yelling resident was saying, and a nearby resident’s report of prolonged yelling and staff discussing touching and groping was not fully captured in the initial documentation. There was also no documentation of behavior monitoring or staff interventions for the yelling that evening, despite prior notes of distressing behaviors, and staff interviews showed inconsistent understanding of reporting and investigation expectations.
Infection Control Failures During Wound Care, Housekeeping, Tracheostomy Care, and Meal Assistance
Penalty
Summary
The facility failed to maintain an infection prevention and control program in multiple areas of care. During wound care for a resident with a right medial malleolus diabetic ulcer who was ordered to be on enhanced barrier precautions (EBP), an LPN donned gloves and completed the wound care but did not don a gown. The resident’s care plan and physician order both indicated EBP for high-contact resident care activities related to the wound, and staff interviews showed differing understandings of when EBP applied and what PPE was required. Housekeeping staff also failed to clean resident toilets in a sanitary manner. In one double-occupancy room, a housekeeper scrubbed the inside of the toilet bowl, then scrubbed the toilet seat, then returned to the bowl, rather than cleaning from the cleanest area to the dirtiest area. In another room, the housekeeper sprayed and wiped multiple bathroom surfaces, including the sink, toilet riser, exterior of the toilet, and bathroom fixtures, but did not clean the inside of the toilet bowl with a toilet brush and did not return to finish the toilet in a sanitary manner. The housekeeper stated the toilet was already clean and said the toilet brush was used only when the toilet was very dirty. Tracheostomy care and suctioning were also performed without maintaining sterility. For one resident, an RN suctioned the tracheostomy and then suctioned the mouth using the same tubing, then changed the trach dressing without changing gloves or performing hand hygiene. For another resident, the RN wore sterile gloves for tracheostomy suctioning but touched the bedside table with the sterile gloves and continued the procedure without changing gloves or performing hand hygiene. During meal assistance, a CNA alternated offering bites of food to two dependent residents using the same hand and did not perform hand hygiene between residents; no hand sanitizer was available at the table. The CNA also prepared one resident’s straw and silverware, then turned to the other resident and continued assisting without hand hygiene between residents.
Expired and Discontinued Medications Left in Cart and Medication Room
Penalty
Summary
The facility failed to ensure drugs and biologicals were properly stored and labeled in accordance with accepted professional principles. During observation of medication cart #2 on the Santa unit, expired and discontinued medications were found in resident-specific drawers, including gabapentin oral tablets that had been discontinued for Resident #17 and oxycodone HCl oral tablets for Resident #48, who had been discharged from the facility. The blister packs still contained multiple pills, and the medications remained in the cart despite being discontinued or no longer needed for the resident. In the medication room, multiple vials of daptomycin IV were observed on a shelf after their expiration dates had passed, including vials expired on 2/27/26, 3/14/26, and 4/2/26. Staff interviews confirmed that the medications should have been removed after expiration or discontinuation. The LPN and RN stated the expired medications should have been discarded, and the ADON said she should have discarded the medication for Resident #17 but was too busy with other nursing tasks. Staff also stated the medication for Resident #48 remained because the DON was on vacation and had the keys to the locked disposal cabinet used for narcotics.
Food Service Failed to Maintain Palatable Temperatures and Texture
Penalty
Summary
The facility failed to ensure residents consistently received food that was palatable in taste, texture, and temperature. The food preparation and service policy stated that proper hot and cold temperatures were to be maintained during food distribution and service, and that temperatures of foods held in steam tables were to be monitored throughout meal service by food and nutrition services staff. Multiple residents reported that room meal trays were cold when delivered, and several also described the food as bland, underseasoned, or otherwise unappetizing. One resident said the food was "sucked in taste" half the time and was always cold in the room. Another said room trays were delivered cold because he was the last room served on the hallway. A third resident said her trays were consistently cold and that requested items were sometimes forgotten. A fourth resident said breakfast trays were always cold and had to be sent back to be warmed up. In a group interview, residents said the food was often undercooked, repetitive, and lacked seasoning. Surveyors observed room tray service and steam table service and found temperature and quality concerns. A test tray served after room trays were delivered contained pork fried rice, sugar snap peas, mini egg rolls, sweet and sour sauce, and gelatin; the fried rice, peas, and egg rolls were measured at 118.4 F, 111.2 F, and 119.1 F, respectively, and were described as unseasoned, chewy, overcooked, mushy, or slimy. During another meal observation, food items on the steam table were initially measured at acceptable hot holding temperatures, but by the end of service several items had fallen below 135 F, including beef fried rice at 133 F, egg rolls at 117 F, diced carrots at 109 F, pureed eggroll at 124 F, pureed carrots at 128 F, and pureed beef fried rice at 106 F. Staff interviews identified that the steam table appeared to heat unevenly, room tray carts were not insulated, the kitchen did not have a plate warmer, and room tray service could be delayed while trays were passed out.
Failure to follow suctioning, tube-feeding, and sleep-monitoring standards
Penalty
Summary
The facility failed to ensure professional standards were followed during suctioning for a resident with a tracheostomy. Resident #66 had diagnoses including sepsis, dementia, tracheostomy, muscle weakness, and dysphagia, and was fully dependent on staff for multiple activities of daily living. During an observation, an RN suctioned the resident through the tracheostomy and then suctioned the resident’s mouth using the same tubing instead of switching to a separate oral Yankauer catheter. The resident began coughing during the procedure. The clinical nurse consultant stated the RN should have used a separate Yankauer catheter after tracheostomy suctioning before suctioning the mouth. The facility also failed to follow accepted standards when administering a water flush through a gastrostomy tube for another resident. Resident #30 had diagnoses including sepsis, dementia, tracheostomy, muscle weakness, and dysphagia, and was dependent on staff for several activities of daily living. The resident had a feeding tube and received 51% or more of calories through the tube. During an observation, the resident was lying flat in bed while an RN disconnected the feeding pump and flushed the gastrostomy tube with 60 mL of water without first elevating the head of the bed to 30 to 45 degrees. The resident’s care plan and physician orders both directed that the head of the bed be elevated during tube feeding and for a period afterward. The facility further failed to create and implement a comprehensive care plan and to follow physician orders for monitoring sleep for a resident with insomnia. Resident #7 had diagnoses including schizoaffective disorder, anxiety disorder, insomnia, depression, and chronic pain, and was cognitively intact. The resident reported insomnia on multiple occasions, leading to repeated Trazodone orders and dose increases. The record showed physician orders to record hours of sleep each shift, but the chart did not contain consistent documentation of the actual number of hours slept during several periods, including after the order was active. The comprehensive care plan did not include a specific focus, interventions, or monitoring for insomnia, and the physician documented that sleep tracking data was not available when reviewing the resident’s response to Trazodone.
Burn from Hot Noodles and Inadequate Supervision During Meals
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision for one resident who sustained a second-degree burn from hot food. Resident #7 had diagnoses including schizoaffective disorder, type 2 diabetes, legal blindness, and end stage renal disease, and the MDS showed he was cognitively intact but required substantial to maximal assistance with most ADLs, including eating. His vision was severely impaired, and he was also documented as needing extensive assistance with feeding. The incident investigation showed that while a nurse was performing wound treatment, a new bruise/blister was found on the resident’s abdomen. The resident reported that he had burned himself the prior morning with noodles, and said he had told a CNA. The CNA stated she was not aware of the blister. The resident denied pain at the time. The wound was treated with silvadene cream and a dry dressing, and the facility identified the root cause as the resident’s blindness/poor vision. Observations and interviews showed the resident was lying in bed with the head of the bed elevated only about 30 degrees and was trying to eat breakfast while lying down with the tray table over him. He told the nurse he could not eat because of nausea. The nurse attempted to adjust the tray table, but it could not be lowered. The record also showed the resident’s abdomen burn was not documented on a weekly skin assessment shortly after the incident, even though later wound care notes and a physician note described the burn from spilling hot noodles and the blistering area on the right upper abdomen.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with surveyors identifying a 7.69% error rate based on two errors in 26 opportunities. During observation, RN #1 prepared medications for a resident and dispensed one glipizide 10 mg tablet into a medication cup even though the resident's May 2026 CPO specified two tablets daily. RN #1 also administered refresh tears ophthalmic solution to the resident, but gave two drops into each eye instead of the ordered one drop to each eye. Record review confirmed the resident's orders for glipizide extended release 10 mg, two tablets every day, and refresh tears ophthalmic solution, one drop to each eye. RN #1 stated he reviewed the MAR while dispensing medications but did not thoroughly review the orders for the resident. The ADON stated RN #1 should have reviewed the MAR before administering medications and said the nurse failed to do so.
Delayed and Incomplete Investigation of Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency centers on the facility’s failure to promptly and thoroughly investigate an allegation of sexual abuse between two residents with severe cognitive impairment, and to adequately document resident monitoring and behaviors surrounding the event. On the evening in question, a CNA heard one resident yelling from her room and entered to find a male resident standing over her bed with his hands on her chest and abdomen area, over her clothing and bedding. Initially, the CNA reported uncertainty about whether the male resident had actually touched the female resident, later clarifying that he had placed his hands on her chest and abdomen. Despite this, the facility did not immediately initiate an abuse investigation at the time of the incident, and the event was not initially considered sexual abuse. The investigation and documentation were delayed and incomplete. The alleged victim was not interviewed until approximately 12 hours after the incident, at which time she did not remember anyone coming into her room or touching her. The alleged perpetrator was not interviewed until about 14 hours after the incident and similarly did not recall entering another resident’s room or hearing anyone calling for help. Both residents had severely impaired cognition, and the delay meant they were unable to provide details of the incident. The facility’s review of hallway video surveillance documented the male resident entering and exiting the female resident’s room and the CNA’s response, but did not establish the exact time he entered the room or how long he remained there before staff intervened. The facility’s investigation also lacked sufficient detail in witness statements and failed to fully explore key information. The CNA’s written statement did not describe the type of touch, the demeanor of either resident, or what the yelling resident was saying. There was no explanation documented for the change in the CNA’s account from the resident’s hands “hovering” to actually touching the other resident. Another resident in a nearby room reported hearing the female resident yelling for help in Spanish for about 10–20 minutes before staff responded, and later overheard staff discussing that a male resident had been in her room touching and groping her; however, this level of detail was not captured in the initial witness statement or incorporated into the investigation. Additionally, there was no documented effort to determine the root cause of the yelling, no documentation of staff monitoring or interventions for the yelling on the evening of the incident, and no timely examination of the alleged victim for injuries that night. Record review further showed that the yelling resident had documented distressing behaviors the day before, including calling out for help, becoming upset when staff attempted to assist, and pinching staff, with a physician notified and new orders initiated. However, there was no documentation of continued behavior monitoring or of her calling out for help on the evening of the alleged abuse, nor of staff actions to monitor and intervene at that time. Staff interviews revealed inconsistent understanding of reporting and investigation expectations, with one CNA stating that after breaking up a resident-to-resident abuse situation and notifying nursing, there was “nothing else to report.” Administrative staff could not demonstrate that the investigator obtained detailed information from the CNA about the exact location and nature of the touching or what the yelling resident was saying, and there was no documentation that later assessments or theories about the male resident’s intent were incorporated into the formal investigation. These omissions and delays in investigation, interviewing, and documentation constitute the core of the cited deficiency.
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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) |
|---|---|---|---|---|
| Westwood Post Acute | 0 mi | ★★★★★ | 0 | 0 |
| Oakwood Care And Rehabilitation | 2.2 mi | ★★★★★ | 10 | 0 |
| Heights Care & Rehabilitation Llc | 2.3 mi | ★★★★★ | 9 | 0 |
| Mapleton Post Acute | 2.5 mi | ★★★★★ | 0 | 0 |
| Villa Manor Care Center | 3.2 mi | ★★★★★ | 11 | 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 October 2026) and official state health department websites.