Center At Lincoln: Accident Hazard Harm Found - CO
The October 24 incident at Center at Lincoln occurred on what was supposed to be the resident's discharge day. CNA #2 told federal inspectors she thought "it was okay to leave her alone for a few minutes because the resident was getting discharged that day."
The resident, identified as Resident #1, had been flagged as impulsive and confused with an increased fall risk. She wore a yellow fall band and had "Call Don't Fall" signage in her room. Her care plan required observation checks by nursing staff.
Despite these precautions, CNA #2 left the resident unattended in the shower chair while she went to get towels and socks. When she returned, the resident had fallen.
"She said when she left the room, Resident #1 fell out of the shower chair," inspectors documented. "CNA #2 said she knew she should not have left the resident alone in the shower."
The resident complained of pain in her right knee and ankle after the fall and received scheduled Tylenol. X-rays revealed a new fracture to her left femur, and she was transported to the hospital.
This was CNA #2's first time working with the resident, despite the woman's documented behavioral challenges. The facility's director of nursing told inspectors that Resident #1 "was impulsive and confused" and "had reached her maximum functional level for discharge but was not independent with ADLs and still required assistance."
The nursing assistant acknowledged her error during interviews with inspectors. "She said she could have called another staff member for supplies instead of leaving the resident to get supplies herself," the report states.
CNA #4, another staff member, explained the facility's fall prevention protocols to inspectors. Residents at risk of falling "typically received frequent checks and resided in rooms that were closer to the nurses' station," she said. Their doors and windows were left open unless staff were providing care.
"For residents who were alert and oriented but were at a fall risk, they relied heavily on the resident to communicate their needs," CNA #4 explained. The facility tried to let residents "do as much as they were capable of doing without intruding on their privacy."
But Resident #1's case presented complications beyond typical fall risks. The nursing home administrator described her as both impulsive and confused, requiring different supervision approaches than alert residents.
The facility had placed Resident #1 in an observation room near the nurses' station with multiple fall interventions. After her fall, staff implemented the "four P's" — frequent assessments designed to keep residents content and decrease fall risk.
The director of nursing blamed the incident directly on the nursing assistant's decision. "The DON said the fall happened because CNA #2 left the resident during her shower to retrieve a towel," inspectors wrote. "The DON said CNA #2 should have called another staff member for the towel instead of leaving the resident by herself because she was impulsive and confused."
Following the fall, facility leadership provided immediate education to CNA #2 about proper fall interventions, specifically instructing her to call for help when assisting residents with showers. The director of nursing admitted they had not conducted facility-wide education about the incident but planned to do so.
The nursing home administrator noted that annual nursing staff training had occurred since the incident, covering proper techniques for activities of daily living and transfers.
CNA #2 demonstrated awareness of basic fall prevention principles during her interview. "CNA #2 said every resident in the facility was at a fall risk because it was a rehabilitation facility," inspectors documented. "She said she remembered the resident having on a yellow wrist band indicating she was a fall risk."
The resident's fall care plan had been created on October 8, just over two weeks before the incident. An interdisciplinary team meeting was convened after her fall to reassess her needs.
LPN #1 initially thought the resident was trying to get out of the shower independently when she fell, but the investigation revealed the nursing assistant had left her unattended.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Center At Lincoln, LLC, The from 2025-11-05 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 LINCOLN, LLC, THE in PARKER, CO was cited for violations during a health inspection on November 5, 2025.
The October 24 incident at Center at Lincoln occurred on what was supposed to be the resident's discharge day.
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.