City Park Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at City Park Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 15, 2021

  Based on observations, interviews and record review, the facility failed to ensure the residents' environment remained free from accident hazards as possible, affecting eight out of 15 sample residents (#65, #73, #67, #79, #46, #42, #22 and #10). Specifically: SMOKING FAILURES The facility failed to develop and implement an effective system of oversight and safety interventions to prevent smoking accidents involving Residents #65, #73, #67, #79, #46, #42. Failures included a lack of identification and communication of residents' smoking risks and safe smoking needs, a failure to develop effective smoking interventions, and a failure to take steps to ensure the facility's smoking policy and procedures were implemented. […]

• Actual harm, isolatedF600Oct 30, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of four residents were free from abuse out of 18 sample residents.Specifically, the facility failed to ensure Resident #1 was free from abuse from Resident #2.Resident #1 was admitted on [DATE] with diagnoses of dementia and right-sided hemiplegia and hemiparesis following cerebral infarction. Resident #2 was admitted on [DATE] with diagnoses of diabetes mellitus type 2, dementia with behavioral disturbance, schizoaffective disorder, heart disease and chronic kidney disease. On 9/7/25 Resident #1 told Resident #2 to shut up. Resident #2 responded by pushing Resident #1. Resident #1 fell to the ground and sustained a left wrist fracture. Findings include: I. […]

• No harm, potential for more than minimal, widespreadF812Oct 12, 2023

  Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure proper hand hygiene and maintain a sanitary environment where food was being served; and, -Ensure the refrigerators on the units were cleaned properly. Findings include: I. Hand washing and use of hair nets A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. […]

• No harm, potential for more than minimal, widespreadF582Jun 1, 2023

  Based on record review and staff interviews the facility failed to provide advance beneficiary protection notification (ABN) for three (#7, #8 and #9) out of three residents reviewed out of nine sample residents. Specifically, the facility failed to ensure Resident #7, #8 and #9 were provided a description of the type of Medicare part A services that were ending, given an estimated cost of services if the resident wanted to pay privately, the reason why Medicare would not continue to pay for the service and the resident's option to appeal. Findings include: I. Facility policy and procedure The facility policy for Advance Beneficiary Notice of Non Coverage (ABN) was requested from the nursing home administrator (NHA) on 6/1/23 at 10:18 a.m. […]

• No harm, potential for more than minimal, widespreadF812Jul 14, 2022

  Based on observations, document review, interviews, and review of the facility policy, the facility failed to ensure food items were stored, prepared, distributed, and served in accordance with professional standards for food safety in 1 of 1 kitchen. Specifically, the facility failed to ensure: 1. the kitchen staff dated, labeled, and covered food items in storage. 2. raw foods were not stored next to ready-to-eat foods. 3. dented cans were discarded. 4. kitchen staff wore a complete hair covering at all times when in the kitchen. 5. kitchen staff maintained the overall cleanliness of the kitchen. 6. kitchen staff maintained complete and accurate refrigerator and freezer temperature logs. This had the potential to affect all residents. Findings included: 1. […]