Center at Park West: Actual Harm Violations - CO
The failure occurred at Center at Park West, where federal inspectors found staff had identified "macerated skin" around Resident #7's wound on August 15 but Wound Care Nurse #1 didn't conduct an assessment until August 19.
Macerated skin becomes soft and breaks down from prolonged moisture exposure, creating conditions that can lead to serious infections and expanded wounds.
The wound care nurse told inspectors on October 23 that she completed wound care on the resident once weekly and measured wounds during those sessions. She said if she forgot to measure a wound, she would remove the dressing and redo the care to obtain measurements.
But her actions didn't match her statements.
WCN #1 had changed the resident's wound vacuum dressing on October 20 but failed to document the care. When she finally documented wound measurements on October 22, she admitted to inspectors that those measurements were actually obtained two days earlier on October 20.
The nurse practitioner responsible for the resident's medical care said she relied on staff assessments and progress notes to monitor wound conditions. NP #1 told inspectors on October 22 that she was never notified of changes to Resident #7's wound or any concerns about moisture-associated skin damage.
"The provider should be notified of any changes to the skin or a wound," she said.
Daily skilled progress notes continued documenting macerated skin around the wound through October 2025, but the notes never indicated the physician had been notified of the resident's deteriorating skin condition.
The breakdown in communication extended beyond the wound care nurse. LPN #2, interviewed during the inspection, said she would notify the wound care nurse of any changes in a resident's skin condition, and the wound care nurse was responsible for notifying the physician.
She said she wasn't aware that Resident #7 refused bed baths, despite the resident being "particular about his care." She acknowledged that daily skilled notes should document when residents refuse care.
The licensed practical nurse also admitted she didn't properly check air mattress settings for pressure relief. She said she would ask residents if they were comfortable and push on the mattress to check air pressure, but she didn't actually verify the settings and thought she was verbally told what they should be.
The Director of Nursing told inspectors that floor nurses should notify the wound care nurse of skin concerns, and certified nursing assistants were educated to report anything abnormal about residents' skin to nurses. All skin conditions should be documented in skin evaluations, she said.
She acknowledged that if tasks weren't marked as completed on treatment administration records, "the assumption would be that the task was not completed."
When confronted with the documentation failures, facility leadership attempted damage control. On October 23, the Director of Nursing told inspectors she had provided WCN #1 with education on correct documentation. She said wound care documentation was completed and back-dated for October 20 when the wound care nurse claimed she had actually measured the wound.
The back-dating occurred after inspectors discovered the gaps in care and documentation.
Federal inspectors determined the facility's failures caused actual harm to residents and affected multiple people. The inspection found that proper wound assessment protocols weren't followed, physician notification requirements were ignored, and staff created false documentation to cover gaps in care.
Resident #7's deteriorating wound condition went unaddressed for days while staff documented obvious signs of skin breakdown but failed to take appropriate action or notify medical providers who could have intervened to prevent further damage.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Center At Park West LLC, The from 2025-10-23 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 20, 2026 · Our methodology
CENTER AT PARK WEST LLC, THE in PUEBLO, CO was cited for violations during a health inspection on October 23, 2025.
Macerated skin becomes soft and breaks down from prolonged moisture exposure, creating conditions that can lead to serious infections and expanded wounds.
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.