Highline Post Acute: Food Safety & Staff Training Fails - CO
Federal inspectors found multiple food safety and infection control failures at Highline Post Acute during an August 15 complaint investigation that revealed systemic problems with medication storage, meal preparation, and staff oversight.
The facility failed to follow enhanced barrier precautions for a resident with a feeding tube. Licensed practical nurse LPN #4 changed the resident's feeding tube dressing and switched nutrition lines without wearing a gown, despite facility policy requiring full protective equipment for such procedures. No sign outside the resident's room indicated enhanced precautions were needed.
"A resident with a feeding tube needed EBP," the director of nursing told inspectors, referring to enhanced barrier precautions that require gowns and gloves during high-contact care.
The infection preventionist confirmed the resident should have been on enhanced barrier precautions, saying "a gown and gloves were required when switching lines and changing dressings." Only after inspectors observed the violation did facility staff place an EBP sign on the resident's door and position protective equipment drawers outside the room.
Kitchen staff repeatedly contaminated ready-to-eat foods during meal preparation. Dietary aide DA #2 wiped his nose with his wrist and the back of his gloved hand while preparing sandwiches, then placed the top slice of bread on the sandwich using the same gloves. Throughout lunch service, staff used the same gloves to handle meal tickets, serving tongs, and food items.
The nutritional services director acknowledged the problems. "Ready-to-eat foods should be handled with clean gloves," she told inspectors. "Gloves should be changed and hand hygiene should be performed after touching items such as tongs, meal tickets and handles to equipment."
Food temperatures posed additional safety risks. Sliced tomatoes measured 45 degrees, cucumbers reached 50 degrees, and tzatziki sauce hit 52 degrees — all above the 41-degree maximum for cold foods. Hot gyro meat served to residents measured only 116 degrees, well below the required 135 degrees.
Expired and improperly stored food filled multiple refrigerators. The Seasons unit refrigerator contained pre-cut cantaloupe with an August 11 use-by date observed on August 14, along with numerous unlabeled items including opened bags of lettuce, shredded cheese, and tortillas. A used surgical mask sat on top of popsicles in the freezer.
The main kitchen walk-in refrigerator held three bottles of heavy whipping cream that expired August 13, discovered the following day. Another refrigerator contained herbal tea with an April 26 use-by date — nearly four months expired.
Residents requiring mechanically altered diets received improperly prepared food that could pose choking hazards. Resident #86, prescribed a level six soft and bite-sized diet, received carrots cut into one to one-and-a-half inch pieces instead of the required one-and-a-half centimeter maximum. Her rice lacked the required gravy to bind it together.
Resident #81, needing level five minced and moist food, received carrots in large pieces rather than the required four-millimeter chopped size. During breakfast, he received a sandwich with meat in one-inch strips and cottage fries with skins, violating multiple texture requirements.
"The kitchen staff were not too knowledgeable on what the different diet textures were and what residents on mechanically altered diets could not have," the nutritional services director admitted.
Resident #23, requiring pureed food, received meals with visible lumps in the entree, carrots, and rice. When asked by staff if she liked the food, she replied, "No."
The facility's meal ordering system functioned poorly. Every resident in the secure unit received pre-poured cranberry juice during three separate meal observations, with no other beverage options offered. Staff claimed they asked residents for preferences, but inspectors observed no such inquiries during multiple meal services.
Resident #63 ordered mashed potatoes but received rice instead. His meal ticket clearly documented the mashed potato order, but staff made no effort to correct the error or offer alternatives. "Nobody wanted to eat rice with pot roast," the resident told inspectors.
Four residents interviewed as a group confirmed systemic problems. "They could circle menu items they wanted on their meal ticket but they did not always receive what they ordered," inspectors documented. "The residents said the kitchen served all of the residents the same food items."
Medication storage violations compounded safety concerns. An insulin vial in the Cherry Creek medication cart bore only "house stock" labeling instead of a specific resident's name. "Each resident should have their own vial or pen for insulin," LPN #1 explained after discovering the violation.
The Capitol Hill medication storage refrigerator contained Boost nutritional drinks stored alongside controlled medications including Lorazepam and injectable diabetes medications. The dormitory-style refrigerator showed ice buildup that could cause temperature fluctuations affecting medication stability.
"Food and nutritional supplements should not be stored with medications in the medication refrigerator in order to prevent contamination," the director of nursing acknowledged. She said she was unaware the facility used dormitory-style refrigerators for medication storage.
The facility couldn't document required annual training for five certified nursing aides. Federal regulations mandate 12 hours of annual in-service training covering areas including dementia care and abuse prevention.
"The facility did not have a staff development coordinator for a while and recently promoted a floor nurse to be the SDC full time," the nursing home administrator explained. The regional director of clinical services admitted the computer-based training system revealed "not all CNAs had not been completing their scheduled training."
The facility lacked tracking systems to monitor staff compliance. "The facility did not have a tracking system in place to track staff training," the regional director acknowledged, promising monthly reviews going forward.
The director of nursing had recently assumed her position and said annual performance reviews hadn't been completed as required. During the survey, facility management implemented plans to ensure timely completion of performance evaluations.
Multiple staff members demonstrated knowledge gaps about proper procedures. Cook CK #1 worked as an agency employee without prior education on mechanically altered food textures. Dietary aide DA #2 incorrectly believed 45-degree food temperatures were acceptable because they exceeded the 41-degree measurement "on their reference sheet."
The violations occurred despite written policies addressing most of the problem areas. The facility's therapeutic diet policy required diet orders to match food service terminology and specified that mechanically altered diets needed texture modifications. Storage policies mandated separate medication and food storage with proper labeling.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highline Post Acute from 2024-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
HIGHLINE POST ACUTE in DENVER, CO was cited for violations during a health inspection on August 15, 2024.
The facility failed to follow enhanced barrier precautions for a resident with a feeding tube.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.