Center at Park West, LLC, the

A complaint survey, prompted by #CO2641184 and #CO2644565 was conducted on 10/21/25 to 10/23/25. Six deficiencies were cited. Based on interviews and record review, the facility failed to ensure one (#2) of six residents out of 17 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to effectively resolve and demonstrate the facility’s response to individual grievances for Resident #2.Findings include:I. Facility policy and procedureThe Grievance policy, revised 1/8/24, was provided by the director of nursing (DON) on 10/23/25 at 3:36 p.m. It read in pertinent part, “If the complaint is verbal, it is the responsibility of the staff member who rec.. Based on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene and good nutrition for two (#3 and #7) of five residents reviewed for ADLs out of 17 sample residents.Specifically, the facility failed to:-Ensure Resident #3 consistently received assistance with meals and showers; and, -Ensure Resident #7 received assistance with showers. II. Resident #7A. Resident statusResident #7, age less than 65, was admitted on 7/.. Based on observations, record review and interviews the facility failed to provide appropriate treatment and services to residents diagnosed with dementia for three (#17, #5 and #3) of five residents out of 17 sample residents.Specifically the facility failed to:-Develop a person-centered care plan to meet Resident #17’s dementia care needs;-Ensure Resident #5 was provided activities to meet her preferences; and,-Develop and implement a person-centered care plan to meet Resident #3’s dementia care needs.Findings include:I. Facility policy and procedu.. Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries to prevent or heal pressure injuries for two (#9 and #7) of six residents out of 17 sample residents.Specifically, the facility failed to:- Accurately identify, document, evaluate and monitor a pressure ulcer for Resident #9;- Ensure Resident #9’s weekly skin assessments were documented thoroughly and accurately; and,- Ensure appropriate wound prevention interventions, including an air mattress, were implemented timely and c.. Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care for three (#2, #8 and #17) of five residents out of 17 sample residents. Specifically, the facility failed to fully develop, review with the resident and/or his responsible party and implement a person-centered baseline care plan within 48 hours of admission for Resident #2, Resident #8 and Resident #17.Findings include: I. Facility policy an.. Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #5) of six residents out of 17 sample residents.Specifically, the facility failed to:-Provide timely, consistent and effective monitoring and appropriate documentation for Resident #1’s left lower leg amputation surgical incision, which resulted in the resident’s transfer to the hospital where she was hospitalized for 10 days with a diagnosis of a left below the knee amputation incision infection; and,-Obtain wound c..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with NFPA 13. NFPA 251. North loaded sprinkler heads 2. Case manager office- escutcheon plates need to be flush with the ceiling. 3. ADL- sprinkler escutcheon plates4. Missing current annual inspection repo.. Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with NFPA 13. NFPA 251.The sprinkler riser room is missing a sprinkler calculation plate. 2.No Hydraulic Design Information on signs on for system(wet, antifreeze systems). 5.2.6* Hydraulic Design Informa.. Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. The fire alarm paperwork for the panel is incomplete, and the elevator detectors were not tested during the annual inspection or in 2023. NFPA 101, Section 9.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the backup emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110.1. Missing corrected coolant inspection report 2. Missing annual load bank test Based on record review and staff interviews duri.. Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.31. 3rd Floor North Fire door won ' t latch. 2. Activity rooms on all floors' doors are missing door closers. NFPA 101, 19.3.6.3.5* Doors shall be provided wi.. Based on observation and staff interviews during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 1011. Emergency lighting: no annual 90-minute inspection report available for review2. Exit Lights: no annual 90-minute inspection report available for reviewNFPA .. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain firewalls in accordance with NFPA 101, 8.3.1.2.1. East stairwell- fire stopping needed around piping 2. Therapy storage- fire-stopping systems needed on wall joists and wall 3. FACP- fire-stopping systems needed 8.3.2.3 Interior .. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. West stairs storage in the stairwell 2. Portable liquid oxygen or storage in egress path by the kitchen.NFPA 101, 7.1.10.1* General. Means of eg.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2.1. Kitchen - Cooking appliances are not supplied with an approved system for return after maintenance or cle.. Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. 1. Oxygen storage room is missing signs for empty and full bottles.2. Portable liquid oxygen tank is stored under nurses station3. Portable liquid oxygen tank concentrators in room 309NFPA 99 11.6.5.2 If empty.. The Colorado Department of Public Safety conducted this initial Life-Safety survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility' s general characteristics.This facility is a three story Type II (111) structure that is prot..

A recertification survey with complaint #CO34397, #CO36617, #CO36630, #CO36737, #CO36748 and #CO36819 was completed on 7/28/24 to 8/1/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 7/28/24 to 8/1/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure one (#98) of six residents reviewed for unnecessary medications out of 40 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #98' s hours of sleep were documented for psychotropic medication use; and,-Ensure person-centered interventions to address Resident #98' s repetitive statements were identified and attempted prior t.. Based on observations, record review and interviews, the facility failed to ensure residents were provided an environment as free of accident hazards as possible for one (#32) of two residents reviewed for accidents and hazards out of 40 sample residents. Specifically, the facility failed to: -Ensure a thorough investigation was conducted after a skin tear was acquired during a staff-assisted transfer for Resident #32; and, -Identify the root cause of Resident #32' .. Based on observations, record review and interviews, the facility failed to keep medical records in a secure and confidential manner. Specifically, the facility failed to ensure nursing staff logged off their workstation when leaving the work area to protect the confidentiality of resident information.Findings include:I. Facility policy and procedureA request for a protected health information policy was requested on 8/1/24, but was not received. II. Observat.. Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen consistent with professional standards of practice, the comprehensive person-centered care plan and the resident' s goal for one (#32) of two residents out of 40 sample residents. Specifically, the facility failed to, for Resident #32: -Ensure a pain assessment was completed that identified the type of pain, the effects of pain on the re.. Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three of three out of eight sampled staff.Specifically, the facility failed to ensure:-CNA #3, CNA #4 and CNA #5 completed the annual dementia and abuse training.Findings include:I. Facility policy and procedureThe Abuse and Dementia Training policy and proc.. Based on record review and interviews, the facility failed to ensure treatment and services being provided met professional standards of quality of care for one (#111) of five residents reviewed for unnecessary medications out of 40 sample residents.Specifically, the facility failed to:-Ensure Resident #111 had blood sugar checks and insulin administered according to physician orders; and,-Follow the physician' s orders for sliding scale insulin parameters by .. Based on record review and interviews, the facility failed to meet all of the requirements for the provision of hospice for one (#19) of one resident reviewed for hospice services out of 40 sample residents.Specifically, the facility failed to ensure a hospice care plan was initiated for Resident #19 to determine who was responsible for resident care.Findings include:I. Facility policy and procedureThe Care Plan policy, revised 2/8/21, was received by the direc..