Center at Park West: Pressure Ulcer Care Failures - CO
Federal inspectors found the lapses at Center at Park West during an October complaint investigation that revealed systemic failures in wound monitoring and documentation. The facility's wound care nurse admitted she had changed a resident's wound dressing but failed to document the care, then backdated records after inspectors questioned the missing entries.
Resident #7 developed macerated skin around a wound site that staff documented on August 15. But the wound care nurse didn't assess the condition until August 19 — five days later. Progress notes through October continued documenting the macerated periwound, but never indicated the physician had been notified of the skin deterioration.
The wound care nurse, identified as WCN #1, told inspectors she completed wound care on the resident once weekly and measured wounds during those visits. She said if she forgot to measure a wound, she would remove the dressing and redo the care to obtain measurements.
But her actions contradicted those statements.
WCN #1 admitted she had changed the resident's wound vacuum dressing on October 20 but didn't document the care. When she finally documented wound measurements on October 22, she told inspectors those measurements were actually obtained two days earlier on October 20. She acknowledged she failed to document the wound care on the day it occurred and didn't label the wound dressing at that time.
During the inspection, WCN #1 changed the resident's wound dressing on October 22 but didn't obtain measurements, despite telling inspectors she always measured wounds during dressing changes.
The nurse practitioner who treated the resident said she was never notified of changes to the wound or concerns about moisture-associated skin damage. NP #1 told inspectors on October 22 that providers should be notified of any skin or wound changes, and that she relied on staff assessments and progress notes to monitor treatment needs.
"She said she did not know about, and was not notified about, any concern for MASD," inspectors wrote, referring to moisture-associated skin damage.
Other staff revealed gaps in basic wound care protocols. An LPN said she would check air mattress settings by asking residents if they were comfortable and pushing on the mattress to check air pressure, rather than following proper procedures. She said she didn't actually check the settings and thought she was verbally told the bed's configuration.
The LPN acknowledged that changes in skin condition should be reported to the wound care nurse, who was responsible for notifying physicians. But the communication chain broke down for Resident #7.
Daily skilled progress notes failed to document the macerated periwound through October, despite the ongoing condition. The Director of Nursing said floor nurses should notify the wound care nurse of skin concerns, and certified nursing assistants were trained to report abnormal skin conditions to nurses.
She said nurses should document all skin conditions in evaluations, and that unmarked treatment records would indicate incomplete care.
The facility's documentation failures extended beyond missed assessments. When inspectors questioned the missing wound care documentation, the Director of Nursing said she provided additional training to the wound care nurse on proper record-keeping.
On October 23, the DON said documentation for the October 20 wound care had been completed and backdated after the wound care nurse admitted the oversight.
The inspection classified the violations as causing actual harm to residents, with few residents affected. Federal regulations require nursing homes to provide necessary care and services to maintain the highest practicable physical well-being of each resident, including proper wound assessment and physician notification of condition changes.
The wound care nurse's admissions revealed a pattern of incomplete documentation and delayed assessments that left the resident's deteriorating condition unaddressed for days at a time.
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.
Resident #7 developed macerated skin around a wound site that staff documented on August 15.
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.