Center at Park West: Care Plan Failures - CO
The facility's wound care nurse documented signs of macerated skin around Resident #7's wound on August 15, 2025, but didn't conduct an assessment 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 nurse practitioner told inspectors on October 22 she was never informed about any changes to the resident's wound condition. "She said she was not notified of any changes in Resident #7's wound," the inspection report states. "She said she did not know about, and was not notified about, any concern for MASD."
MASD refers to moisture-associated skin damage, a serious condition that can lead to painful breakdown of skin tissue.
The nurse practitioner explained she relied on staff assessments and progress notes to monitor wound treatment changes. She emphasized that providers should be notified of any skin or wound changes.
When inspectors interviewed the wound care nurse on October 23, they uncovered a pattern of documentation failures. The nurse admitted she had changed the resident's wound vacuum device on October 20 but failed to document the wound care entirely. She said the measurements she recorded on October 22 were actually obtained two days earlier.
"She said she did not document wound care on 10/20/25 or label the wound dressing at that time," inspectors wrote.
The wound care nurse told inspectors she completed wound care on Resident #7 once weekly and measured wounds during those sessions. She claimed that if she forgot to measure a wound, she would remove the dressing and restart the wound care process to obtain measurements.
But her actions contradicted her stated protocol. Despite saying she had only changed the resident's wound dressing once on October 22, she hadn't obtained measurements during that documented session.
An LPN interviewed the same day revealed gaps in basic wound monitoring procedures. She said she would check air mattress settings by asking residents if they were comfortable and manually pressing the mattress to gauge air pressure. However, she admitted she didn't actually check the air mattress settings and thought she was verbally told the bed settings.
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 was unaware that Resident #7 had refused bed baths, despite saying daily skilled notes should document when residents refuse care.
The Director of Nursing told inspectors that floor nurses should notify the wound care nurse of skin concerns, and certified nursing assistants were trained to report any abnormal skin conditions to nurses. She said nurses should document all skin conditions in skin evaluations.
Regarding documentation failures, the Director of Nursing stated that if treatment administration records weren't marked, "the assumption would be that the task was not completed."
The inspection found that daily skilled progress notes through October 2025 failed to document the macerated periwound condition. Skin and wound progress notes continued documenting macerated skin around the wound through October, but treatment records showed no indication that medical providers were informed of the deteriorating condition.
On October 23, after inspectors completed their investigation, the Director of Nursing said she had provided the wound care nurse with education on correct documentation. She acknowledged that wound care documentation was completed and back-dated for October 20, when the wound care nurse claimed she had obtained measurements.
The facility's failures resulted in actual harm to the resident, whose wound condition deteriorated without proper medical oversight or timely intervention.
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 5, 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 through October continued documenting the macerated periwound, but never indicated the physician had been notified of the skin deterioration.
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.