Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ridgeview Post Acute during CMS and state inspections, most recent first.
The facility failed to report four separate allegations of physical abuse between residents to the State Survey and Certification Agency within the required two-hour timeframe. The written abuse reporting policy directed the NHA or designee to submit initial reports within 24 hours, which did not match state requirements. Record review showed that each of the four incidents of alleged physical abuse between pairs of residents was reported between 13 and 26 hours after occurrence. In interviews, the NHA stated he believed the two-hour rule applied only when serious bodily harm occurred, and the clinical resource nurse acknowledged that the facility missed the required two-hour reporting window for these allegations.
A resident with dementia and a documented history of verbal and physical aggression, including throwing objects and hitting others with pillows, shared a room with another cognitively impaired resident who had no history of aggression. In the early morning, a CNA heard arguing, found the aggressive resident attempting to remove a pillow from under the roommate’s head, and separated them. About 20 minutes later, the aggressive resident took a pillow from her own bed and struck the roommate three times, causing the roommate to become upset and yell for staff to remove the aggressor. Documentation and interviews confirmed the incident began with a verbal exchange and that the victim reported being hit several times without retaliating.
The facility failed to maintain a safe and sanitary environment, with issues such as sheetrock damage, chipped paint, debris, and nonfunctional exhaust fans in resident rooms. Work orders for these concerns were not found in the facility's system, despite monthly inspections. Additionally, improper storage of urine collection devices posed infection control risks.
The facility failed to document and monitor wandering behaviors for two residents in a secured unit, leading to deficiencies in care. Despite being at risk for elopement and wandering, the facility did not maintain records of interventions or their effectiveness. Staff interviews revealed a lack of awareness and documentation regarding these issues.
The facility failed to document narcotic medication removal from locked drawers on two medication carts. Discrepancies were found between narcotic logs and actual counts, with nurses admitting to not documenting removals immediately after administering medications to residents. The DON acknowledged the issue, despite recent staff education on controlled substance documentation.
The facility failed to properly store and label medications, as observed in two medication carts and a storage room. An Albuterol inhaler and a tuberculin vial were not labeled with opening dates, and Haloperidol was found for a discharged resident. Medications were found on the floor, indicating improper disposal and supervision. A resident had artificial tears without a physician's order. Staff interviews confirmed these deficiencies, showing non-compliance with storage and administration protocols.
A facility failed to ensure proper communication and documentation of hospice services for a resident with severe cognitive impairments. The care plan did not define hospice services, and staff could not locate the hospice binder or access electronic records. The DON admitted to a lack of a designated hospice coordinator and inadequate communication processes.
A facility failed to prevent a physical altercation between two residents, both with histories of aggression. Despite previous incidents involving one resident, the care plan lacked updated interventions. The altercation involved hair-pulling and was deemed substantiated physical abuse. The facility's response of separating and redirecting the residents was ineffective.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report four separate allegations of physical abuse between residents to the State Survey and Certification Agency as required by state law. The facility’s Abuse Prevention and Reporting policy, revised in June 2025, directed the administrator or designee to complete the initial report to the state agency within 24 hours via the occurrence reporting portal and complete the report within five days, which did not align with the state requirement to report any abuse allegations within two hours of the incident. Record review showed that an allegation of physical abuse between Resident #1 and Resident #2 occurred on 11/18/25 at 8:20 a.m., but was reported on 11/19/25 at 10:22 a.m., 26 hours after the incident. An allegation of physical abuse between Resident #3 and Resident #4 occurred on 1/19/26 at 5:00 a.m., but was reported at 7:07 p.m. the same day, 14 hours after the incident. Further record review showed that an allegation of physical abuse between Resident #5 and Resident #6 occurred on 2/8/26 at 8:30 a.m., but was reported on 2/8/26 at 9:40 p.m., 13 hours after the incident. Another allegation of physical abuse between Resident #4 and Resident #11 occurred on 3/22/26 at 11:59 a.m., but was reported on 3/23/26 at 11:56 a.m., 24 hours after the incident. During interviews, the nursing home administrator, DON, and clinical resource nurse stated that the administrator believed the two-hour reporting requirement applied only to allegations resulting in serious bodily harm. The clinical resource nurse stated she showed the administrator the occurrence reporting manual and acknowledged that the facility missed the two-hour reporting guidelines for the four physical abuse allegations.
Failure to Prevent Resident-to-Resident Physical Abuse Involving a Known Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from resident-to-resident physical abuse. In the early morning, a certified nurse aide (CNA) heard arguing and activity in a room shared by two residents. When the CNA entered, one resident was standing near the roommate’s bed and attempting to remove a pillow from beneath the roommate’s head while the roommate was lying supine in bed. The CNA separated the residents and assisted the aggressive resident back to her side of the room. Approximately 20 minutes later, the same resident took a pillow from her own bed, went back to the roommate, and struck the roommate three times with the pillow before staff intervened again. The resident who initiated the physical contact had dementia with moderate cognitive impairment, insomnia, COPD, depression, and a documented history of physical and verbal aggression toward others. Her care plan, revised shortly after the survey, reflected a history of being physically aggressive, making threats to kill staff, making repetitive hostile statements, throwing food, drinks, and markers at other residents, pulling another resident’s hair bow, and throwing and hitting others with pillows. Identified triggers included touching her belongings, crowds, strangers, or actions taken from behind her. Interventions listed in the care plan included locating her room near the nurses’ station, decreasing interactions with other residents when possible, keeping her at arm’s length from others, providing distraction and redirection, and providing one-to-one observation during waking hours. The roommate who was the victim of the physical aggression had dementia, COPD, stroke, and kidney disease, required substantial assistance with ADLs, and had no documented behavior symptoms directed toward others. Her behavioral care plan noted paranoia and accusatory behavior related to dementia and stroke, including yelling about people on the television watching her and calling out that she was naked when she was not. After the incident, nursing documentation recorded that she was the recipient of physically aggressive behavior, that the aggressor made physical contact three times before separation by staff, and that the incident began with a verbal exchange between the roommates. The victim stated she was hit several times for no reason, did not hit back, denied pain or discomfort, and expressed that she did not want to remain in the same room with the aggressor. Staff interviews confirmed that the victim was upset and screamed for staff to get the other resident away from her during the incident.
Environmental and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one of its units. Observations revealed multiple deficiencies in several resident rooms, including sheetrock damage, chipped paint, debris accumulation, and nonfunctional bathroom exhaust fans. Additionally, there were issues with the flooring, such as torn linoleum and separated tiles, as well as missing or damaged heater covers and ceiling tiles. These environmental concerns were not addressed despite the facility's policy to maintain a homelike environment and provide necessary housekeeping and maintenance services. During an environmental tour with the nursing home administrator (NHA) and the maintenance supervisor (MS), it was noted that the facility's computerized system for submitting work orders did not contain any requests for the observed issues. The MS stated that resident rooms were inspected monthly and routinely audited for environmental issues, yet the deficiencies persisted. The NHA confirmed that staff had been trained to use the computerized system for work orders, but no records of the reported concerns were found. Interviews with the NHA and the director of nursing (DON) revealed further issues with infection control practices. Urine collection hats and a male urinal were improperly stored in resident rooms, posing potential infection control risks. The DON acknowledged that these items should not be stored in resident rooms and should be disposed of or stored in plastic bags. The presence of plungers and toilet brushes in resident bathrooms was also noted, which were later removed during the survey.
Failure to Document and Monitor Wandering Behaviors
Penalty
Summary
The facility failed to ensure that two residents, who resided in a secured unit, were free from involuntary seclusion. The facility did not maintain the required ongoing documentation of the review and revision of care plans to meet the criteria and assess if the interventions met the needs of the residents. Specifically, the facility did not document wandering behavior, attempted diversional interventions, or the effectiveness of these interventions for the residents. Resident #19, an 82-year-old with Alzheimer's disease and dementia, was identified as being at high risk for elopement and wandering. Despite this, the facility's records did not show any documentation of wandering behavior or interventions from December 2023 to July 2024. The resident's care plan indicated a risk for elopement, but there was no evidence of monitoring or documentation of wandering behaviors or the effectiveness of interventions after an incident in December 2023. Resident #100, an 81-year-old with dementia and other health issues, was also at risk for wandering. The facility's records showed episodes of aimless walking and wandering, but there was no documentation of interventions used or their effectiveness. The care plan for this resident was only initiated during the survey, and it lacked documentation of wandering behavior and interventions. Interviews with staff revealed a lack of awareness and documentation regarding the effectiveness of interventions for both residents.
Failure to Document Narcotic Medication Removal
Penalty
Summary
The facility failed to ensure that narcotic medications were documented on the narcotic log at the time of removal from the locked narcotic drawer on two of four medication carts. During observations, discrepancies were noted in the narcotic logs compared to the actual counts of medications. Specifically, on the [NAME] unit, a registered nurse (RN) administered a hydrocodone/acetaminophen pill to a resident but forgot to document the removal of the medication from the locked controlled substance drawer. Similarly, on the Golden unit, another RN failed to document the removal of several medications, including lorazepam, pregabalin, oxycodone, and tramadol, from the locked controlled substance drawer after administering them to residents. Interviews with the nursing staff revealed that the nurses were aware of the requirement to document narcotic removals immediately but had not done so. The Director of Nursing (DON) acknowledged the issue and indicated that staff had been provided with recent education regarding the documentation of controlled substances. However, the failure to document the removal of narcotics at the time of administration was still observed, indicating a lapse in adherence to the facility's Controlled Medications Storage and Reconciliation policy.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in two medication carts and one medication storage room. Specifically, an Albuterol inhaler was found without a date label on the Golden unit medication cart, and two boxes of Haloperidol were found labeled for a resident who had been discharged a week earlier. Additionally, an open vial of tuberculin was found in the Montrose medication storage room without a date label, indicating a failure to adhere to the facility's policy of dating medications upon opening. Further observations revealed medication tablets on the floor near the Sterling unit medication room and the nurses' station, which were identified as Apixiban, Aspirin, and Acetaminophen. This indicates a failure to ensure medications were properly disposed of and that staff did not adequately supervise residents to ensure medications were swallowed. The presence of these medications on the floor suggests lapses in medication administration and disposal procedures. Additionally, a resident was found with artificial tears in their room without a physician's order for self-administration, which was not in compliance with the facility's policy. Interviews with the DON and other staff confirmed these deficiencies, highlighting a lack of adherence to medication storage and administration protocols. The facility's policy requires medications to be stored properly and dated upon opening, and discontinued medications to be promptly removed and disposed of, which was not consistently followed in these instances.
Deficiency in Hospice Service Communication and Documentation
Penalty
Summary
The facility failed to ensure that hospice services provided to a resident met professional standards and principles. Specifically, the facility did not establish a communication process between the facility and the hospice provider for a resident receiving hospice care. The facility's policy required collaboration with hospice, including documentation and record-keeping requirements, but this was not effectively implemented. The resident, who had severe cognitive impairments and was receiving hospice services, did not have a clearly defined care plan outlining the services to be provided by the hospice provider or the facility. Additionally, there was a lack of accessible documentation of hospice care visits in the resident's records. The facility's staff, including an LPN, were unable to locate the hospice binder that should have contained documentation of visits from the hospice provider. The DON acknowledged that the facility did not have a designated hospice coordinator at the time and that the communication process was not documented. The DON also admitted that the unit nursing staff did not have access to the hospice's electronic medical records, which contributed to the deficiency in communication and documentation.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically failing to prevent an altercation between two residents. Resident #256, who had a history of verbal and physical aggression related to dementia, engaged in a physical altercation with Resident #19. The incident occurred in the dining room where both residents were seated and began arguing, which escalated to Resident #256 pulling Resident #19's hair. Despite previous incidents involving Resident #256, the facility did not implement new person-centered interventions to prevent further altercations. Resident #256 had a documented history of aggressive behavior, with multiple incidents involving other residents prior to the altercation with Resident #19. The care plan for Resident #256 identified verbal and physical aggression but lacked updated interventions following previous incidents. The facility's investigation revealed that Resident #256 had been involved in four prior incidents with other residents, yet the care plan did not reflect new strategies to address these behaviors. Resident #19, who also had a history of verbal and physical aggression, was involved in the altercation with Resident #256. The facility's response to the incident was to separate and redirect the residents, but this intervention was deemed ineffective. The nursing home administrator acknowledged the altercation as substantiated physical abuse, highlighting the facility's failure to implement effective measures to prevent such incidents.
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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 Commerce City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Irondale Post Acute | 1.3 mi | ★★★★★ | 13 | 1 |
| City Scape Rehabilitation & Care Center Llc | 3.6 mi | ★★★★★ | 0 | 0 |
| Thornton Care Center | 4.6 mi | ★★★★★ | 3 | 0 |
| Denver North Care Center | 5 mi | ★★★★★ | 17 | 0 |
| Villas At Sunny Acres, The | 5 mi | ★★★★★ | 1 | 0 |
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