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🔎 Elk Ridge Health And Rehabilitation Center

Inspection Results


Inspection Overview

Elk Ridge Health And Rehabilitation Center has been cited for a total of 62 deficiencies since we began saving each survey.

In Colorado, the average facility has **29.64 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-12-10
Correction Date: 2024-12-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-11-30
Correction Date: 2024-02-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-11-30
Correction Date: 2023-12-26
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-11-30
Correction Date: 2023-12-26
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-11-30
Correction Date: 2023-12-26
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2023-10-11
Correction Date: 2023-11-09
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-05-25
Correction Date: 2023-08-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2023-05-25
Correction Date: 2023-07-07
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-05-25
Correction Date: 2023-06-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2023-05-25
Correction Date: 2023-06-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2023-05-25
Correction Date: 2023-06-14
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-03-01
Correction Date: 2023-04-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2023-03-01
Correction Date: 2023-04-01
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-07-20
Correction Date: 2022-08-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-07-20
Correction Date: 2022-08-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that residents are free from significant medication errors.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-03-24
Correction Date: 2022-04-22
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-09-07
Correction Date: 2021-09-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Dispose of garbage and refuse properly.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-03-01
Correction Date: 2021-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2020-12-01
Correction Date: 2020-12-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2020-12-01
Correction Date: 2020-12-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2020-12-01
Correction Date: 2020-12-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2020-12-01
Correction Date: 2020-12-21
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2020-09-08
Correction Date: 2020-10-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2020-09-08
Correction Date: 2020-10-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2020-09-08
Correction Date: 2020-10-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2020-09-08
Correction Date: 2020-10-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-09-08
Correction Date: 2020-10-07
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2020-06-09
Correction Date: 2020-07-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-10-10
Correction Date: 2019-11-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**