Center at Park West: Grievance Rights Failures - CO
Federal inspectors found multiple documentation failures in wound care at Center at Park West during an October 2025 complaint investigation. The facility's wound care nurse had changed a resident's wound dressing only once during the inspection period, despite claiming to provide weekly care.
Resident 7's medical records showed signs of macerated skin documented on August 15, 2025. The wound care coordinator didn't assess the condition until August 19 — five days later.
The macerated skin around the wound continued through October 2025, according to daily skilled progress notes. Staff never documented notifying the physician about the resident's skin deterioration.
During interviews, the facility's nurse practitioner said she wasn't told about any changes to Resident 7's wound. She said she had no knowledge of moisture-associated skin damage concerns.
"The provider should be notified of any changes to the skin or a wound," the nurse practitioner told inspectors on October 22. She relied on staff assessments and progress notes to monitor wound treatment changes.
The wound care coordinator told inspectors she completed wound care on Resident 7 weekly and measured wounds during each treatment. But when she forgot to measure a wound, she said she would remove the dressing and redo the entire wound care procedure.
Records showed the coordinator had only changed Resident 7's wound dressing once during the inspection period — on October 22. She hadn't obtained measurements during that treatment.
The coordinator admitted to changing the resident's wound vacuum on October 20 but never documented the wound care. She told inspectors the measurements she recorded on October 22 were actually taken two days earlier, on October 20.
She failed to document wound care on October 20 or label the wound dressing at that time.
A licensed practical nurse interviewed during the inspection said she would check air mattress settings by asking residents if they were comfortable and pushing on the mattress to check air pressure. She didn't actually verify the settings and thought she was verbally told the bed specifications.
The LPN said she would notify the wound care coordinator about any changes in a resident's skin condition. The coordinator was responsible for notifying the physician, she said.
She described Resident 7 as "particular about his care" but wasn't aware the resident refused bed baths. Daily skilled notes should indicate when residents refuse care, she told inspectors.
The director of nursing said floor nurses should notify the wound care coordinator about skin concerns. Certified nursing assistants were educated to alert nurses about anything abnormal with residents' skin conditions.
All skin conditions should be documented in skin evaluations, the director said. If treatment administration records weren't marked, staff would assume tasks weren't completed.
On October 23, the director of nursing told inspectors she had provided the wound care coordinator with education on correct documentation. She said wound care documentation was completed and back-dated for October 20, when the coordinator claimed she had measured the wound.
The facility's documentation failures meant physicians couldn't make informed decisions about wound treatment changes. The resident's deteriorating skin condition went unreported to medical providers for months.
Federal inspectors determined the deficient wound care practices caused actual harm to residents. The facility affected few residents with the documented violations, but the failures represented systemic problems with wound assessment and physician communication protocols.
The inspection revealed a pattern of incomplete documentation and delayed assessments that compromised resident care. Staff interviews showed confusion about responsibilities for notifying physicians and properly documenting wound care procedures.
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: August 4, 2026 · Our methodology
CENTER AT PARK WEST LLC, THE in PUEBLO, CO was cited for violations during a health inspection on October 23, 2025.
Federal inspectors found multiple documentation failures in wound care at Center at Park West during an October 2025 complaint investigation.
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.