14
Inspections
30
Deficiencies
1
Actual Harm or Above
43
Occurrences
February 25, 2026
Last Inspection
S/S D/E/F Potential for harmS/S J Immediate jeopardy
The most recent inspection of BRIARWOOD HEALTH CARE CENTER on record is dated February 25, 2026. Across 14 published inspections, state surveyors cited 30 deficiencies, 1 of which reached actual harm or immediate jeopardy.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
SNF/NF Dual Certification
Administrator
Van Gorder, Andrew Ryan
Owner
LIFE CARE CENTERS OF AMERICA, INC.
Phone
(303) 399-0350
Payor Source
Medicare, Medicaid, Private Pay
City
DENVER
ZIP
80206-2016
Inspections & Citations
14 inspections · 30 deficiencies2/25/2026Complaint Survey · ID 1F1A5D-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2734114 was conducted on 2/24/26 to 2/25/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/25/2026Licensure Complaint Survey · ID 1F1A5F-H1No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A survey with #CO2734115 was completed on 2/24/26 to 2/25/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
7/16/2025Complaint Survey · ID ETDU111 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A survey, prompted by #CO1936676, #CO1936677 and #CO1936678 was conducted 7/15/25 to 7/16/25. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0760Residents are Free of Significant Med Errors▼
Findings
Based on record review and interviews, the facility failed to ensure one (#5) of 12 residents reviewed for medication management were free from significant medication errors out of 12 sample residents. Resident #5 was admitted to the facility on 12/10/21 with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain) and epilepsy (seizure disorder). On 6/7/25 the facility received a delivery from the pharmacy. Licensed practical nurse (LPN) #1 signed for the delivery and did not open the box to check the contents. LPN #1 placed the box in the medication room. When LPN #1 went to administer Resident #5’s Dilantin medication (a medication used to prevent seizures) on 6/20/25 and 6/21/25, she was unable to locate the medication. This resulted in Resident #5 missing three consecutive doses of Dilantin. On 6/21/25 Resident #5 was transferred to the hospital for a possible seizure. The resident was monitored with a continuous electroencephalography (cEEG) (monitors brain activity), which showed focal status epilepticus (a prolonged seizure) as well as secondary generalized seizures. The resident was treated in the hospital with anticonvulsants intravenously (IV). Specifically, the facility failed to ensure Resident #5 was given her antiseizure medication as ordered. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/15/25 to 7/16/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/27/25. I. Medication error on 6/20/25 and 6/21/25On 6/7/25 LPN #1 received and signed for a delivery from the pharmacy. She did not open the box and inventory the contents. She placed the delivered box in the medication room. On 6/20/25 at 6:55 p.m. LPN #1 documented she was unable to administer Dilantin 150 milligrams (mg) due to not having the medication. On 6/21/25 at 8:21 a.m. LPN #1 documented she was unable to administer Dilantin 100 mg due to not having the medication. On 6/21/25 at 4:58 p.m. LPN #1 documented she was unable to administer Dilantin 150 mg due to not having the medication. On 6/21/25, Resident #5 was sent to the hospital for a possible seizure and treatment. On 6/22/25 it was discovered that Resident #5’s Dilantin medication was in the box that was delivered by the pharmacy on 6/7/25 and was not administered to the resident as ordered. II. Facility’s performance improvement planThe performance improvement plan (PIP) the facility implemented in response to Resident #5’s medication errors was provided by the nursing home administrator (NHA) on 7/15/25 at 12:18 p.m. The plan documented the problem identified was three doses of Dilantin were not given to Resident #5, resulting in the resident being sent to the hospital. The plan revealed the following:A. Root cause analysisLPN #1 failed to open the medication delivery box and the medication remained in the medication room, which was not noticed by any employees and the protocol for reporting unavailable medications to the physician was not followed. B. Identification of other residentsResident #5 was transferred to the hospital when she started showing signs of seizure activity. A medication administration record (MAR) audit of all residents who received anticonvulsant medication was implemented on 6/25/25 to ensure they were all receiving their anticonvulsant medications. The audit was still ongoing for monitoring. B. Systemic changesThe director of nursing (DON) completed a verbal corrective action form with LPN #1 and educated her on the process of receiving medication deliveries from the pharmacy and the process of when a resident was missing a medication. The education was given over the phone on 6/23/25 and the form was signed on the next shift that LPN #1 worked, which was 6/26/25. The staffing development coordinator (SDC) reeducated nursing staff on proper medication handling and documentation procedures and proper notification of the physician, the DON and the unit manager (UM) when medications were not available. Nursing staff were also given handouts on medication handling, when a medication was not available and significant medication errors. All nursing staff were educated by 6/27/25. C. MonitoringThe UM would conduct a weekly MAR audit on all residents receiving anticonvulsant medications to ensure no doses were missed. The UM would turn in the audit to the DON to double-check the audit. The audit was started on 6/25/25 and was ongoing. The UM or the DON would conduct a weekly audit on medications received to ensure that the medications are put away timely. The first audit was conducted on 6/20/25 and was ongoing. The UM or the DON would audit all medication rooms to ensure received medications were not left in the medication room. The DON conducted the first audit on 6/25/25 and was ongoing. The facility’s determined date of compliance was 6/27/25. III. Professional referenceAccording to Potter, P.A., Perry, A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, "Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication." IV. Facility policy and procedureThe Medication Administration policy, revised 2/13/23, was provided by the regional director of clinical services on 7/16/25 at 10:08 a.m. It read in pertinent part, “Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, right education and information.”The Reordering, Changing, and Discontinuing Medication Orders policy, revised 7/1/24, was provided by the regional director of clinical services on 7/16/25 at 10:16 a.m. It read in pertinent part, “ Facilities are encouraged to reorder medications electronically or by fax whenever possible.“Facility staff should review the transmitted re-orders for status and potential issues and pharmacy response. “The facility should retain a copy of the refill/order form communicated to the pharmacy to reconcile the medications delivered by the pharmacy against what was ordered.”V. Resident #5A. Resident statusResident #5, age 83, was admitted on 12/10/21. According to the July 2025 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebrovascular disease and epilepsy. The 6/6/25 minimum data set (MDS) assessment indicated the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The assessment documented that the resident was dependent on staff for the majority of her activities of daily living (ADL). The assessment documented that the resident was taking anticonvulsant medication and had a diagnosis of epilepsy. B. Resident #5’s representative interview Resident #5’s representative was interviewed on 7/15/25 at 1:38 p.m. The representative said Resident #5 was receiving her medications as ordered from what he knew. The resident’s representative said he assumed Resident #5 was getting her medications, as when one of her medications became unbalanced, she had to be sent out to the hospital. The representative said Resident #5 was sent to the hospital two or three weeks prior. The representative said Resident #5 had been having seizures due to an imbalance in her medications, but the resident had been fine since she was readmitted to the facility. C. Record reviewThe June 2025 CPO revealed Resident #5 had physician’s orders for the following daily scheduled medications: Dilantin Infatabs Tablet Chewable 50 milligrams (mg) for seizures). Give 100 mg by mouth one time a day every Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday, ordered on 9/1/23. Dilantin Infatabs Tablet Chewable 50 mg. Give 150 mg by mouth every evening shift, ordered on 9/1/23. Review of the June 2025 MAR (from 6/1/25 to 6/31/25) documented that Resident #5 did not receive the 150 mg dose of Dilantin on the evening of 6/20/25 and 6/21/25 and the 100 mg dose of Dilantin on the day shift on 6/21/25. The administration notes for each of the missed doses entered by LPN #1 documented that the Dilantin Infatabs were on order for Resident #5. A progress note, dated 6/21/25 at 9:25 p.m. revealed Resident #5 was sent to the hospital for a possible seizure. The hospital after visit summary, dated 6/24/25, documented Resident #5 was diagnosed with focal status epilepticus (a constant, unending seizure) caused by missed doses of her anti-seizure medication. The summary documented she was treated with intravenous anti-seizure medications while at the hospital and then restarted on her home medications. It was recommended that she was to take all her anti-seizure medications consistently to prevent any further seizures. The hospital discharge summary, dated 6/24/25, documented Resident #5 presented from the nursing home with abnormal twitching with unclear symptoms during the transport with emergency medical services (EMS) to the hospital. The discharge summary documented Resident #5’s symptoms escalated during transport to more generalized shaking, flexion and stiffness of her extremities. She was treated by EMS with 12.5 mg of Versed (a sedative that can treat seizures). Upon arrival to the emergency department at the hospital, Resident #5 was lethargic and appeared to be postictal (period immediately following a seizure). The discharge summary documented that she was treated with a Keppra (anticonvulsant medication) loading dose and neurology recommended a fosphenytoin (anticonvulsant medication) load since her level was low due to her missed doses of Dilantin. She was also given phenobarbital (anti-seizure medication) intravenously. The summary documented the resident's Dilantin level was 8.3 mcg/ml (micrograms/milliliter) which was considered low, upon her admission to the hospital. On day two of her hospital stay her focal status epilepticus resolved and she was restarted on her home medications, but she was still being monitored at the hospital. On day four she was discharged back to the nursing home. The physician progress note, dated 6/26/25, documented Resident #5 had been at her baseline since her return from the hospital. The note documented the physician went over Resident #5’s medications with the unit nurse that was onsite. VI. Staff interviewsThe pharmacist was interviewed on 7/15/25 at 12:37 p.m. The pharmacist said she was not notified of the three missed Dilantin doses for Resident #5. She said the therapeutic level for Dilantin was between 10 to 20 mcg/ml. She said the half-life (the time it takes the medication to decrease by half in the blood stream) of Dilantin varied depending on how the resident metabolized the medication. She said the half-life could go down to as low as seven hours, depending on how the resident metabolized and processed the medication. She said that she would expect the facility to administer the medications per the physician’s orders. LPN #1 was interviewed on 7/15/25 at 1:47 p.m. LPN #1 said she was really busy on 6/7/25 when the box was delivered from the pharmacy. She said she had only read the label on the outside of the box. She said she did not open the box and look inside. She said she was unaware that there was medication inside of the box. She said because of her mistake, Resident #5 had a seizure and went to the hospital. She said she tried to order the medication from the pharmacy before it ran out. She said when a medication ran out, she would let the pharmacy know as well as the physician. She said she thought she had let Resident #5’s physician know, but she could not remember if she did. She said that she should have documented that the medication was not given and if she had contacted the physician. She said there was a button in the electronic medical record (EMR) to reorder medications. She said the pharmacy would let the facility know if the reorder was too early, had been ordered already, or if there were any other issues with the medication order. She said there was a print out at the nurses’ station which would let the staff know the status of the reorder. She said when the medication was not available she documented on the MAR the code number 10, which meant the medication was on order. Registered nurse (RN) #1 was interviewed on 7/16/25 at 10:10 a.m. RN #1 said he was recently trained on receiving medication orders from the pharmacy. He said he could not remember the date that he received the education. He said when receiving a bag from the pharmacy, the contents should always be inventoried and put away in its proper area. He said a pharmacy order should never be left in the medication room unopened. He said if a medication was missing he would let the pharmacy know, the DON and the physician. He said if it was a medication that was needed right away, he would get authorization from the DON to open the emergency kit (E-kit) and use the medication from there. The DON was interviewed on 7/16/25 at 11:34 a.m. The DON said when the nurses received an order from the pharmacy they should open the box to make sure the medication was correct and put the medication in the correct place. The DON said when a medication was not in the medication cart, the nursing staff should be checking to see if the medication had been reordered and let the pharmacy know. She said that if the missing medication was one that could be found in the E-kit, they could open the E-kit and use it. She said that Dilantin was not in the E-kit and the physician should have been notified. She said Resident #5’s physician was not notified of the missed doses of medication but was notified when she was sent to the hospital. She said the nurses had to use their own discretion on when to notify the physician on missed doses of medication. The DON said LPN #1 might not have realized how important it was to let the physician know because Resident #5 was also on phenobarbital (another medication used to prevent seizures). She said the facility discovered the medication was in the medication room in a box on 6/22/25. She said when LPN #1 called the pharmacy, the pharmacy told her that the medication had been delivered and that was when they started searching the facility for the medication. She said they had missed the medication in the box on 6/20/25 when they did their medication room audit because they were looking for bags of medication, not boxes. She said that since 6/27/25, when all nursing staff had been educated, the facility had not had any missed doses of antiseizure medication.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Complaint Survey · ID 35QG11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO39256 and Incident #39404 was conducted on 3/10/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/4/2024Revisit: Recertification Survey · ID EKNO22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.
Plan of correction
The state did not require a plan of correction for this citation.
11/6/2024Revisit: Recertification Survey · ID EKNO12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 11/6/24 for all previous deficiencies cited on 10/3/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
10/30/2024Recertification Survey · ID EKNO212 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility's general characteristics. The facility consists of two (2), four story (4) Type 1 (222) structures licensed for two hundred one (201) beds, and the facility reports a census of sixty eight (68) at the time of the survey. Building A-1 (West Building) and building A-2 (East building) are both protected by a complete NFPA 13 fire sprinkler system. Each building contains their own sprinkler and fire alarm system and they are not interconnected. The two buildings are connected with a bridge on the third level and a tunnel on the basement level. The bridge and tunnel are separated with 2 hour fire rated construction and opening protectives on both sides of the East and West buildings. The facility was surveyed on October 30, 2024 for compliance to fire safety requirements using the National Fire Protection Association (NFPA) 2012 Life Safety Code, Chapter 19, Existing Facilities. The facility will meet these requirements when the following deficiencies are corrected. The deficiencies were discussed with the Maintenance Director during the walk-through inspection of the building and the survey concluded with a discussion of the deficiencies with the facility Maintenance Director during the exit conference.
Plan of correction
The state did not require a plan of correction for this citation.
0521HVACS/S F▼
Findings
Based on documentation review and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105. This was evidenced by the following:1. The most recent fire damper inspection report from 4/26/2023 stated there were two fire dampers that failed inspection/testing. NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.
Plan of correction · submitted by the facility
Corrective Action: On 11.14.24, Total Performance, evaluated the two "fire dampers" mentioned on the 04.26.23 that failed. The technician sated the sprinkler room damper is not a damper or a fire damper, it is a turning vain inside the duct. This is not a fire damper it is simply for airflow for lack of an elbow duct. The fire damper in the hallway at room 407, the technician stated there is a damper that supplies air for the room, however, it is pneumatic actuator, and it is not tied into any fire protection system. The pneumatics on the is building has been disabled a long time ago, approximately 15 years ago. Other residents who could be affection by the same deficient practice: 100% of all residents could be affected by the same deficient practice. Systemic Change: Complete fire damper inspections as required and ensure the follow up is complete. The Maintenance Director will maintain the records for the inspection. Monitoring: The Maintenance Director of designee will schedule the damper inspection/testing as required. The Maintenance Director or designee will ensure follow up from the inspection will be completed. The Maintenance Director or designee will maintain the records for inspection and follow up in our TELS system.
0923Gas Equipment - Cylinder and Container StoragS/S E▼
Findings
Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. CO2 cylinders are not properly secured (next to the soda machine in the basement). NFPA 99, Section 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. This deficiency can potentially affect occupants, including staff and visitors within the basement smoke compartment. Deficient items were identified during the survey and discussed with the Administrator at the exit conference.
Plan of correction · submitted by the facility
Corrective Action: On 10.30.24 the Maintenance Director secured the CO2 cylinders at the time the surveyor pointed this potential out to him. Other residents who could be affection by the same deficient practice: During the survey on 10.30.24 the surveyor and our team audited 100 % of the facility. No other deficient practice was noted. Systemic Change: The facility will properly chain or support freestanding CO2 cylinders in a stand. Monitoring: Maintenance Director or designee will audit free standing CO2 cylinders weekly for 30 days to ensure that they are secured and monthly thereafter for 90 days.
Plan of correction · submitted by the facility
Corrective Action: On 10.30.24 the Maintenance Director secured the CO2 cylinders at the time the surveyor pointed this potential out to him. Other residents who could be affection by the same deficient practice: During the survey on 10.30.24 the surveyor and our team audited 100 % of the facility. No other deficient practice was noted. Systemic Change: The facility will properly chain or support freestanding CO2 cylinders in a stand. Monitoring: Maintenance Director or designee will audit free standing CO2 cylinders weekly for 30 days to ensure that they are secured and monthly thereafter for 90 days.
10/3/2024Recertification Survey · ID EKNO114 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A Recertification Emergency Preparedness Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Colorado Department of Public Health and Environment (CDPHE) on 09/30/24 through 10/03/24. There were no deficiencies cited.
Findings · record 2 of 2
A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Colorado Department of Public Health and Environment (CDPHE). Four deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0550Resident Rights/Exercise of RightsS/S D▼
Findings
Based on observation, record review, interview, and review of facility policy, the facility failed to ensure two residents (Resident (R)51 and R72) out two residents observed with catheter bags out of 20 sampled residents reviewed had dignity bags for their use of a foley catheter. This failure had the potential to cause embarrassment and loss of dignity to the two residents. Findings include:Review of the facility's policy, provided by the facility, titled "Dignity" with an issued date of 05/06/19 and reviewed on 09/25/23 revealed "Each resident has the right to be treated with dignity and respect. "The procedure was to "promote resident independence and dignity while dining" and "refrain from practices demeaning to the resident, such as leaving urinary catheter bags uncovered."1. Review of R51's "Face Sheet" located in the electronic medical record (EMR) under the "Admission Record" revealed R51 was admitted to the facility on 04/28/23. Review of R51's annual "Minimum Data Set (MDS)" located in the EMR under the "MDS" tab with an Admission Reference Date (ARD) of 04/03/23 revealed a "Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition. The "MDS" indicated R51 had an indwelling suprapubic catheter. During an observation on 10/01/24 at 10:19 AM revealed R51's foley catheter (indwelling urinary catheter) was attached to the bed frame on the side facing the door and there was a clear plastic bag over the catheter but you could still observe the bag and urine from the resident's doorway. 2. Review of R72's "Face Sheet" located in the EMR under the "Admission" tab revealed R72 was admitted to the facility on 08/14/24. Review of R72's significant change "MDS" located in the EMR under the "MDS" tab with an ARD of 08/16/24 revealed a "BIMS" of zero out of 15 which indicated he was unable to complete the cognition assessment. The "MDS"" revealed that R72 had an indwelling urinary catheter. During an interview on 10/01/24 at 12:01 PM Certified Nursing Assistant (CNA)1 confirmed the catheter bags were not covered yesterday or earlier today for R51 and R72. CNA1 stated they had the blue dignity bags today and she had placed them on R51's and 72's catheter bag. CNA1 stated the catheter bag should be covered for resident dignity and privacy. During an interview on 10/02/24 at 10:59 AM with Licensed Practical Nurse (LPN)1 revealed a catheter bag should be covered with a privacy bag to keep it private from others to maintain the dignity of a resident. LPN1 revealed there was a master key to the supply room, on the second floor, that staff had access to and could get a blue privacy bag anytime. During an interview with the Director of Nursing (DON) on 10/02/24 at 11:25 AM revealed catheter bags should be in a privacy bag to ensure the residents dignity. During an interview with the Administrator on 10/02/24 at 4:30 PM revealed the catheter bag should be covered with a dignity bag to ensure a resident maintained their dignity.
Plan of correction · submitted by the facility
F550 Residents Rights/Exercise of RightsCorrective Action:R #51 and R# 72 were provided with Privacy bags on 10/2/24. Identification of Others:Privacy bags on 10/5/24 all residents with foley catheters were audited for privacy bags - out of the 7 – two of the residents did not have privacy bags. The two residents were immediately given privacy bags. Systemic Measures:On 10/23/24 communication went to nursing staff via COVR regarding privacy bags need to be on the wheel chairs and beds at all times. (COVR is a communication application the facility uses for communication with staff that also can receive attachments; provides staff their schedules)Nursing staff will be educated on the use of privacy bags; importance of maintaining resident dignity thru the use of privacy bags - how to properly install privacy bags – and monitoring catheter with privacy bags in use. Nursing staff will be trained by 10/27/24 – nursing staff on vacation will be trained immediately upon return. New hire nursing staff will be trained during orientation. Monitoring: Charge nurse/Unit manager/SDC (staff development coordinator)/IP (infection preventionist) will conduct daily checks x 2 weeks for compliance and assuring all residents with foley catheter have privacy bags both on wheel chair and bed – monitoring will then be done weekly for the next 90 days or until substantial compliance achieved. Monitoring will be documented on paper audit tool. The audits are observation for privacy bags. The Director of Nursing (DON)/Designee will track and trend results of the audits for the next 90 days or until substantial compliance is met and present it to the Performance Improvement Committee monthly for input and review. This report will be done on paper and turned in to Qapi
0695Respiratory/Tracheostomy Care and SuctioningS/S D▼
Findings
Based on observation, interview, record review, and facility policy review, the facility failed to ensure four residents (Resident (R) 2, R6, R30, and R41) out of a total sample of 20 residents reviewed for respiratory services received appropriate care of their oxygen tubing. This created the potential for infection. Findings include:Review of the facility policy titled "Oxygen Administration (Safety, Storage, and Maintenance)", issued 12/03/18 and revised 02/27/24 and under the sub section titled "Infection Control" indicated " ...Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out ..."1. Review of R2's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR), revealed R2 was admitted to the facility on 09/15/22 with diagnoses including chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Review of R2's "Physician Orders" located under the "Orders" tab of the EMR revealed an order for oxygen at three liters per minute (lpm), continuously, per nasal cannula and an order to change the oxygen tubing every night shift, on every Sunday. During an observation on 10/01/24 at 1:25 PM revealed R2's oxygen tubing had no date to indicate when the tubing change was last changed. 2. Review of R6's "Admission Record," located under the "Profile" tab of the EMR, revealed R6 was admitted to the facility on 10/28/22 with a diagnosis of obstructive sleep apnea. Review of R6's "Physician Orders" located under the "Orders" tab revealed an order for the "titration of oxygen to keep her pulse ox (measurement of the oxygen content of the blood) over 90%, the use of Bi-pap (breathing assistance via a mask and oxygen) at night, and an order to change the oxygen tubing every night shift on every Sunday."During an observation on 10/01/24 at 2:00 PM revealed R6 had her oxygen on and there was no date on the tubing to indicate when it had last been changed. 3. Review of R30's "Admission Record," located under the EMR under the "Profile" tab, revealed R30 was admitted to the facility on 10/20/17. Review of R30's "Physician Orders"" revealed orders for oxygen at two liters continuously per nasal cannula and an order to change the oxygen tubing and nebulizer circuit every night shift on every Sunday as per the Physician order. During an observation on 09/30/24 at 2:46 PM and on 10/02/24 at 11:00 AM revealed R30's oxygen tubing was not dated to indicate when the last time it was changed. 4. Review of R41's "Admission Record," located in the EMR under the "Profile" tab, revealed R41 was admitted to the facility on 08/03/24 with a diagnosis which included chronic obstructive pulmonary disease (COPD). Review of R41's "Physician Orders" revealed an order for oxygen at three liters/minute continuously per nasal cannula and an order to change the oxygen tubing and nebulizer circuit every night shift every Sunday. During an observation on 10/01/24 at 1:50 PM indicated R41's oxygen tubing was not dated to indicate the last time it had been changed. During an interview with the Unit Manager on 10/02/24 at 1:00 PM, the Unit Manager confirmed that the oxygen tubing for R2, R6, R30, and R41 had not been changed on the night shift on Sunday per physician's orders.
Plan of correction · submitted by the facility
F695Respiratory Oxygen tubing Corrective Action:On 10/07/2024R #2;R#6;R#30 and R# 41 - immediately received new oxygen tubing and tubing was dated. 10/7/24: Audit completed on all residents with Oxygen, tubing was dated. Identification of Others:All residents with OxygenAudit was conducted on 10/7/24 am and 10/14/24 for oxygen tubing replaced – oxygen tubing was replaced and dated on Sunday night. No issues identifiedSystemic ChangesOxygen Policy and education regarding oxygen tubing changed and dated was sent out via COVR system to all nursing staff. (COVR is a communication application the facility uses for communication with staff that also can receive attachments; provides staff their schedules)Education was given to night shift nurses and c.n.a (certified nurse aide) with the understanding they have the responsibility of changing out the oxygen tubing and dating the tubing weekly on Sunday night. The night nurse will document the change in the TAR (treatment administration record). Should oxygen tubing need to be changed on a prn (as needed) basis – the nurse will document the change in the TAR and assure the new date is on the tubing. Education to the day and evening nursing staff to ensure understanding that they are responsible for monitoring residents and changing out oxygen tubing and dating the changed tubing as needed. Education to all nursing staff - Education to be complete by 10/27/24. MonitoringDON/designee will audit 10 residents weekly to ensure current oxygen tubing is dated beginning 10/14/24 for the next 90 days and or substantial compliance - Audits will include observation and this will be recorded on a paper audit sheet. The Director of Nursing/Designee will track and trend results of the audits for the next 90 days or until substantial compliance is met and present it to the Performance Improvement Committee monthly for input and review.
0698DialysisS/S D▼
Findings
Based on record review, interview, and review of facility policy, the facility failed to ensure weights were documented for one (Resident (R) 31) of two residents reviewed for dialysis out of a sample of 20 residents. This had the potential for the resident to have unmet care needs. Findings include:Review of the facility policy titled "Hemodialysis Offsite Policy" effective 04/24/19 and last reviewed 09/06/24 indicated that under the "Procedure" section revealed, "the facility should weigh the resident." Under the "Day of Dialysis" section indicated, "the facility should observe the vascular access site prior to dialysis and initiate the "Pre/Post Dialysis Communication Form" to be sent to the dialysis with the resident." The "Day of Dialysis" section indicated "on return to the facility, facility staff should obtain vital signs and complete the "Pre/Post Dialysis Communication Form."Review of R31's "Admission Record," located in the EMR under the "Profile" tab, revealed R 31 was admitted to the facility on 06/25/17 with a diagnosis including, end stage renal disease (ESRD). Review of the "Physician Order" in R31's EMR revealed an order for R31 to have dialysis on Tuesdays, Thursdays, and Saturdays. Review of "Pre/post Dialysis Communication Form" located in the EMR under the "Documents" tab dated between 06/01/24 and 09/28/24 indicated R31's pre and post weights, which were to be done by the facility staff according to the "Pre/post Dialysis Communication Forms," were not completed as follows: 06/01/24-pre and post weights06/04/24-pre and post weights06/06/24-pre weight06/08/24-pre and post weights06/11/24-pre and post weights06/20/24-pre and post weights06/22/24-pre and post weights06/25/24-pre and post weights06/27/24-post weight07/02/24-pre weight07/08/24- pre and post weight07/11/24-pre and post weight07/13/24-pre and post weight07/18/24-pre and post weight 08/01/24-pre and post weight08/03/24-pre and post weight08/08/24-post weight08/10/24-pre and post weight08/13/24-pre and post weight08/15/24-pre and post weight08/17/24-pre and post weight08/20/24-pre and post weight08/22/24-pre and post weight08/24/24-pre and post weight08/31/24-pre and post weight09/03/24-pre and post weight09/05/24-pre and post weight09/07/24-pre weight09/10/24-pre and post weight09/12/24-pre and post weight09/14/24-pre weight09/17/24-pre and post weight09/21/24-pre and post weight09/24/24-pre and post weight09/26/24-pre and post weight09/28/24-pre and post weightDuring an interview on 10/03/24 at 2:37 PM with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) both confirmed the "Pre/post Dialysis Communication Records," did not contain the pre and/or post weights as listed above for R31.
Plan of correction · submitted by the facility
F698Dialysis Corrective Action:10/4/24 - received dialysis treatment sheets from dialysis on R #31 to include pre/post weights and vitals. 10/4/24 - Audit conducted on all 3 residents who have dialysis -Identification of Others:3 residents have HD (hemodialysis)Systemic Changes: RN (registered nurse)/LPN (licensed practical nurse) will be educated on the importance of assuring the dialysis communication sheets are completed upon return from dialysis and if any missing information they are to call the dialysis center and obtain the information. Education will be done by 10/27/24RN/LPN will be educated on the process for addressing missed weights/information on communication sheets and document in progress note. - Education will be done by 10/27/24On October 20th Dialysis POC and Dialysis policy was sent to ALL LPN/RN via COVR system (COVR is a communication application the facility uses for communication with staff that also can receive attachments; provides staff their schedules)10/24/24 – Education on Dialysis communication sheets and process for lack of information given at All staff In-serviceMonitoring: Charge nurse/Unit Manager/SDC/IP will audit 3x a week to ensure completion of the communication sheet for each resident and any missing information will be addressed immediately with the dialysis unit for 90 days or substantial compliance. DON/designee will audit weekly to ensure dialysis communication sheets are filled out completely for the next 90 days or until substantial compliance.is audit will be done on a paper audit form. The Director of Nursing/Designee will track and trend results of the audits for the next 90 days or until substantial compliance is met and present it to the Performance Improvement Committee monthly for input and review.
0919Resident Call SystemS/S D▼
Findings
Based on observation, record review, interview, and review of facility policy, the facility failed to ensure one resident (Resident (R)51) observed out of 20 sampled residents had their call light within reach. This failure had the potential to cause R51 needs to not be met .Findings include:Review of the facility's policy, provided by the facility, titled "Keeping a Resident Room in Order," issued :08/09/2019 and reviewed 06/02/24 revealed "The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely, call lights must be within easy reach of the resident in bed and out of bed."Review of R51's "Face Sheet" located in the electronic medical record (EMR) under the "Admission Record" revealed R51 was admitted to the facility on 04/28/23 with diagnoses of cognitive communication deficit, muscle weakness, need for assistance with care, and schizophrenia. Review of R51's annual "Minimum Data Set (MDS)" assessment located in the EMR under the "MDS" tab with an Admission Reference Date (ARD) of 04/03/23 revealed a "Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition..Review of R51's comprehensive "Care Plan" with a target date of 10/20/24 located in the EMR under the "Care Plan" tab revealed a problem for ADL (activities of daily living) self-care deficit and one of the interventions was to encourage R51 to use the bell to call for assistance. Review of the problem for impulsiveness and impaired memory revealed an intervention was for the call light to be in reach. During an observation on 09/30/24 at 1:20 PM revealed R51's in bed with his eyes closed and the call light was hanging on the drawers beside his bed and not in his reach. During an observation on 10/02/24 at 3:17 PM revealed R51s was in bed with his eyes closed and his call light was on the floor behind the bed and not in the resident's reach. During an interview on 10/02/24 at 3:17 PM with Licensed Practical Nurse (LPN)1 she confirmed the call light was on the floor and not within R51's reach. LPN1 revealed the call light should have a clip on it so it can be clipped to the blanket, and it did not have a clip. LPN1 stated R51 was able to utilize the call light. During an interview on 10/02/24 at 4:30 PM with the Administrator revealed the call light should be in reach of the resident and not on the floor. During an interview on 10/03/24 at 1:10 PM with the DON revealed call lights should be in reach of the residents for safety. The DON further revealed the call light should have a clip on it so it can be clipped to the bed so it would not fall on the floor. The DON stated the resident needed to be able to use the call light if he needed help.
Plan of correction · submitted by the facility
F 919Corrective Action:10/4/2024 R #51 - call light clip was placed on call light - call light then clipped to bed - Identification of OthersA whole house audit was completed on 10/21/24 to ensure call lights in place while in wheelchair and bed. Audit of call light clips completed on 10/21/24. Systemic Measures:Education for Call lights to be in reach while in bed or wheelchair and call lights must have clip on it was sent on 10/20/24 via COVR App – Policy sent on 10/20/24 via COVR app. to all staff. (COVR is a communication application the facility uses for communication with staff that also can receive attachments; provides staff their schedules)10/24/24 Education provided at the All Staff In-service regarding call lights in place with clips. On 10/24/24 – the maintenance team corrected all call lights needing clips. Monitoring:The facility shall complete the following actions:The NHA (nursing home administrator)/DON/Designee will audit of 10 Residents weekly to ensure that call lights are within Residents reach in bed or wheelchair for the next 90 days or when substantial compliance audits will include monitoring of call light placement. The audit form is paper. The NHA/DON will track and trend results of the audits weekly to include monitoring of call light placement for the next 90 days or until substantial compliance is met and present it to the Performance Improvement Committee monthly for input and review. This audit form is paper.
8/24/2023Revisit: Recertification Survey · ID 392O22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.
Plan of correction
The state did not require a plan of correction for this citation.
6/27/2023Revisit: Complaint, Recertification Survey · ID 392O12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 6/27/23 for all previous deficiencies cited on 5/9/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
43 records6/12/2026Misappropriation of Property · ID 26020470015Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/12/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Client (A) alleged $30 had been stolen. During the course of the investigation, the healthcare entity conducted a search and offered options to secure any valuables. Review of resident account activity revealed client (A) withdrew $58 two days earlier. Client (A) still had $28 in their possession. Staff indicated they witnessed client (A) getting snack items from the vending machine and that he might have forgotten to obtain the change. Staff planned to assist client (A) as needed. The facility could not corroborate client (A)'s allegation of theft. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/13/2026 · released to the public 7/20/2026.
5/16/2026Misappropriation of Property · ID 26020470013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/18/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Client (A) alleged $50 was stolen from their purse, and they believed the money had been taken by staff (1). The money had not been secured. During the course of the investigation, the healthcare entity suspended staff (1), notified the police and conducted a search and interviews. A lockbox was offered and staff encouraged them to safeguard any additional valuables. Staff (1) denied the allegation and reported they opened client (A)'s drawers for incontinence supplies. The facility could not establish if client (A) had that amount of money in their possession or if it was deliberately taken. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/7/2026 · released to the public 7/14/2026.
5/15/2026Misappropriation of Property · ID 26020470011Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/15/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Client (A) alleged someone stole some clothing items from their closet. The alleged thefts started over three years ago to just as recently as one month ago. During the course of the investigation, the healthcare entity conducted searches, record reviews and interviews. One item was located, but the most recent item reported being taken could not be found. Management offered to replace clothing items and installed a lock on the client's closet door. The facility could not determine if the items were deliberately taken or if client (A) had those clothing items originally. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/31/2026 · released to the public 8/7/2026.
5/7/2026Misappropriation of Property · ID 26020470010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/7/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Client (A) alleged a vape pen had been stolen from their purse about a month ago. During the course of the investigation, the healthcare entity conducted a search and interviews. A lockbox was provided. Management reported a vape pen had been found one month earlier, but client (A) denied that it belonged to them. The facility was not able to determine if someone deliberately took a vape pen. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/16/2026 · released to the public 7/23/2026.
4/14/2026Sexual Abuse · ID 26020470009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a sexual abuse event. Client (A) alleged someone attempted to rape them. Client (A) provided descriptive details about the alleged perpetrator. During the course of the investigation, the healthcare entity conducted an assessment and interviews. Management attempted to identify the alleged assailant and notified the police. Client (A)'s care plan was updated to reflect staff should provide care in pairs. Education was provided to client (A) to keep the door open or cracked for staff monitoring. Staff said they did not witness any visitors, and no staff matched the description of the alleged perpetrator. Nursing indicated there were no signs of a physical struggle or external sexual trauma. The facility concluded client (A) experienced a hallucination/delusional episode along with increased confusion due to end-of-life care. Hospice staff re-evaluated client (A)'s medications and staff provided comfort. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/22/2026 · released to the public 7/29/2026.
4/8/2026Misappropriation of Property · ID 26020470008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/8/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Client (A) alleged someone stole their coat. During the course of the investigation, the healthcare entity conducted a search, interviews and record reviews. Management provided a lock for client (A)'s closet door, and they were encouraged to secure their items. With further interviews, client (A)'s timeline changed, as now they have said it had been stolen several months ago. The facility could not establish if the client had that item in their possession. No other clients reported having any concerns about missing items. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/29/2026 · released to the public 7/6/2026.
3/18/2026Misappropriation of Property · ID 26020470005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/18/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Client (A) reported several clothing items were missing and claimed they had been stolen. During the course of the investigation, the healthcare entity conducted a search, reviewed client (A)'s inventory list and conducted interviews. Management could not confirm if these items were present in the facility. A decision was made to reimburse client (A), and a lock was provided for the closet. Staff assisted client (A) update the inventory list. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/22/2026 · released to the public 5/29/2026.
1/23/2026Verbal Abuse · ID 26020470003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/23/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Client (A) alleged a group of individuals have been coming into his room at different times, making noises and gestures. Client (A) reported feeling afraid he was going to be harmed, and that this has been occurring for quite some time. During the course of the investigation, the healthcare entity suspended one staff member (only person out of the group to be identified), provided emotional support and notified the police. Management requested care in pairs. No one could corroborate client (A)’s allegation or timeline of events. Management requested a mental health referral for client (A), as the family member reported he might be experiencing delusions. Staff (1) returned to work and was reassigned. The event could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/3/2026 · released to the public 4/10/2026.
1/16/2026Misappropriation of Property · ID 26020470002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Client (A) alleged someone stole $200 and some shoes from their room. During the course of the investigation, the healthcare entity conducted a search and interviews. Management reminded client (A) to utilize the lockbox provided for securing any valuables. Staff discovered $132 in the room, but client (A) said the other amount was still missing. Shoes were present in the room, but client (A) indicated another pair was still missing. The facility could not establish what shoes were missing or how much money the client initially had in their possession, and client (A) had recently gone out on a shopping activity. No other staff or clients reported having any awareness of missing or taken items. Client (A)’s allegation could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/25/2026 · released to the public 4/1/2026.
11/15/2025Physical Abuse · ID 25020470024Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/15/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Staff heard a commotion and observed client (B) pushing client (A)’s shoulder as they swatted at one another. After staff separated the clients, client (A) alleged client (B) had lifted him by the neck, held him up against the wall and was choking him. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. Client (A) reported having 6/10 pain initially to his neck but later told staff there was no pain. No visible injury was observed. A room change occurred to separate the clients. Staff’s observation of the incident did not align with client (A)’s account. With client (B)’s physical state, staff reported he lacked the strength to pick up or hold client (A) against the wall. The event could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 1/22/2026 · released to the public 1/29/2026.