Center at Park West: Daily Care Failures - CO
Federal inspectors found the delayed response at Center at Park West in October, where Resident #7 developed moisture-associated skin damage around an existing wound. Progress notes from August 15 documented signs of macerated skin, but wound care nurse #1 didn't assess the condition until August 19.
The skin deterioration continued through October 2025, with daily skilled progress notes failing to document the macerated periwound area. Staff progress notes consistently recorded macerated skin around the wound, but inspection reports show no indication that the physician had been notified of the resident's skin deterioration.
When inspectors interviewed the facility's nurse practitioner on October 22, she said she was not notified of any changes in Resident #7's wound condition. "She said she did not know about, and was not notified about, any concern for MASD," inspectors wrote, referring to moisture-associated skin damage.
The nurse practitioner told inspectors that providers should be notified of any changes to skin or wounds, and that she relied on staff assessments, progress notes, signs and symptoms of infection, and laboratory results for treatment decisions.
Licensed practical nurse #2 revealed gaps in basic care protocols during her interview. She said she would check air mattress settings by asking residents if they were comfortable and pushing on the mattress to check air pressure, but admitted she didn't actually check the settings and thought she was verbally told the bed configurations.
The LPN said she would notify the wound care nurse of any changes in a resident's skin condition, and that the wound care nurse was responsible for notifying the physician. She claimed she wasn't aware that Resident #7 refused bed baths, though she acknowledged that daily skilled notes should indicate if a resident refused care.
Documentation problems extended beyond delayed assessments. Wound care nurse #1 told inspectors she completed wound care on Resident #7 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 wound care to obtain measurements.
But the nurse's actual practices contradicted her stated procedures. She admitted to inspectors that she had only changed Resident #7's wound dressing once, on October 22, and hadn't obtained measurements at that time.
The documentation irregularities deepened when wound care nurse #1 revealed she had changed Resident #7's wound vacuum on October 20 but didn't document the wound care. She told inspectors the measurements she documented on October 22 were actually obtained two days earlier, on October 20. She admitted she didn't document wound care on October 20 or label the wound dressing at that time.
The facility's director of nursing outlined the chain of communication that should have protected the resident. Floor nurses should notify the wound care nurse of any skin concerns, she said, and certified nursing assistants were educated to notify nurses of anything abnormal with residents' skin. Nurses should document all skin conditions in skin evaluations.
The director acknowledged a critical documentation principle: if the treatment administration record wasn't marked, the assumption would be that the task wasn't completed.
After inspectors identified the violations, the director of nursing said she provided wound care nurse #1 with education on correct documentation. She said documentation on wound care was completed and back-dated for October 20, when the wound care nurse claimed she had measured the wound.
The inspection found that few residents were affected by the wound care documentation failures, but inspectors determined the violations caused actual harm to at least one resident whose deteriorating skin condition went unassessed and unreported to medical providers for days.
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.
Progress notes from August 15 documented signs of macerated skin, but wound care nurse #1 didn't assess the condition until August 19.
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.