Grace Pointe: Resident Harm, Safety Failures - CO
The primary care physician told inspectors the fracture "looked as if it had to have been hit laterally" and could not have happened from rolling or moving in bed. He said the dark purple bruise was "about the size of a fist, four-five inches" when he examined it on July 17.
"It probably happened by her bumping into something," the doctor said. "It most likely happened on the evening shift."
Staff initially tried to explain the injury as occurring during a routine transfer, but the nursing home administrator later admitted those notes were "documented under assumption." The assistant director of nursing said staff "did not measure bruises because everyone measures them so differently."
Inspectors observed dangerous transfer practices firsthand during their visit. Staff used an extra-large sling on a resident who should have received a medium, causing the person to slide dangerously low during the lift. The resident's head became covered by the improperly sized sling, and their bottom dropped through the sling opening.
CNA #6 acknowledged using the wrong equipment initially. "She initially used the red sling with Resident #3, she said she thought it was a medium, but they were told to use the extra-large sling with the green border with her because it gave her more stability with her fracture," the inspection report stated.
The aide blamed room setup and resident positioning for the transfer difficulties. She said "the set up in the room with all the large furniture made it difficult to move the lift" and that the resident "was pushing back when they tried to lean her forward."
During the problematic transfer inspectors witnessed, staff positioned the resident incorrectly. CNA #6 admitted afterward that "she should have had Resident #3's legs on the side closest to the bed."
The facility's leadership revealed systemic problems with transfer assessments and staff training. The nursing home administrator said she was "unsure if there was an official sling assessment," despite residents requiring specific sling sizes for safe transfers.
The assistant director of nursing told inspectors that "the nurses should be making the decisions about the sling size, not the CNAs," but CNA #6 said "the DON had made the decision to use the extra-large sling" for the injured resident.
Staff received retraining after a separate incident on October 2 that was "considered a fall." However, the training appeared inadequate given the continued unsafe practices inspectors observed weeks later.
The nurse practitioner interviewed about the July fracture said she "did not think the fracture could have happened while Resident #3 was lying in bed" and heard "it happened during a transfer." She recommended that therapy staff conduct transfer assessments "since they were the ones who know most about body mechanics."
Transfer status decisions at Grace Pointe relied on informal handoffs rather than formal assessments. The assistant director of nursing explained that "based on what the admitting nurse received in report was what the residents transfer status was" and "the transfer status would stay the same until there was a change in condition."
The injured resident had previously been downgraded from a stand-pivot transfer to requiring mechanical lift assistance. The administrator said the resident "was at one time a stand-pivot transfer, but she had so many bad days that at some point she was moved to a sit-to-stand."
After the fracture incident, staff continued making assumptions about proper techniques. Both CNAs told inspectors they "normally tried to get the sling as far under her as possible," despite this approach contributing to the dangerous positioning inspectors witnessed.
The facility's response focused on staff retraining rather than systematic equipment assessment or transfer protocols. Management acknowledged the severity only after the primary care physician's examination confirmed the fracture could not have occurred naturally.
The doctor was unsure whether the resident with dementia would have been able to respond or report pain when the injury occurred, leaving the exact circumstances unclear despite the clear evidence of trauma.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grace Pointe Cont Care Sr Campus, Skilled Nursing from 2025-10-22 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: August 4, 2026 · Our methodology
GRACE POINTE CONT CARE SR CAMPUS, SKILLED NURSING in GREELEY, CO was cited for violations during a health inspection on October 22, 2025.
He said the dark purple bruise was "about the size of a fist, four-five inches" when he examined it on July 17.
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.