Irondale Post Acute
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
morning and had placed the bed as a barrier behind his room door entrance preventing the staff from getting into his room. Staff had to go through the bathroom from the room next door to offer breakfast to the resident and the resident got up and said expletives aggressively. The resident continued to state I don't belong here. I want to get out of here! Redirection was attempted but was unsuccessful. The 8/26/25 at 12:00 p.m. psychiatric follow-up note, documented by a physician's assistant, revealed that Resident #4 shared that he had had thoughts in the past about trying to leave the unit by breaking a window, but stated
he would have turned himself in afterward.The 9/9/25 at 9:52 a.m. nurse note revealed Resident #4 had refused his breakfast and all his medications. Later the resident requested his breakfast be replaced. The nurse staff went to the kitchen to obtain a new plate and upon delivery the resident threw the plate across
the dining room and stated that the nursing staff was trying to poison him with his medications and were trying to give him food from another resident. The resident then called 911. Police officers responded and
the resident was stating that he wanted to leave and return to the homeless shelter and that he did not belong there. The resident was also displaying paranoia related to his sister. The police officer, the NHA and nursing staff reoriented the resident and explained cares and the process needed to be able to discharge safely. The resident verbalized understanding.The 9/20/25 at 12:09 p.m. nurse note, written by registered nurse (RN) #2, revealed Resident #4 did not want the nurse to touch his AICD monitor. The nurse observed
the monitor was unplugged and the resident was agitated.The 9/20/25 at 12:10 p.m. medication administration note revealed the resident refused his skin assessment. RN #2 had attempted the assessment three times.The 9/20/25 at 9:00 p.m. nurse note, written as a late entry by the DON, revealed
the executive director (ED), family, ombudsman, police department and medical doctor were all notified. -However, the note did not specify what the notification was regarding. -Review of Resident #4's EMR revealed there were no other progress notes documented on 9/20/25.The 9/21/25 at 3:06 a.m. nurse note, written by licensed practical nurse (LPN) #1 revealed that at 8:30 p.m. on 9/20/25 she entered Resident #4's room to give him his medications and Resident #4 was not sitting on his bed and the door to his bathroom was locked. LPN #1 returned a few minutes later and Resident #4 was still not visible in his room.
LPN #1 knocked on the bathroom door with no answer. LPN #1 opened the door and Resident #4 was not there. LPN #1 asked the certified nurse aide (CNA) #2 if he was aware that Resident #4 was not in his room. CNA #2 stated that the last time he saw Resident #4 was at dinner time and Resident #4 had refused hi
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Irondale Post Acute
7150 Poplar St Commerce City, CO 80022
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0867
F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
they had standard issues that they worked on and addressed reportable incidents, falls, infections, hospitalization, weight loss, diet changes, admission, discharges, resident council, grievances and trends.NHA #1 said the QAPI committee identified issues and how they were improving with any corrective actions. NHA #1 said the QAPI committee put forth a good faith attempt to identify and correct its own quality deficiencies and it was a team effort. NHA #1 said the facility had at least one process improvement plan going and most recently it was regarding glucometer calibration. NHA #1 said that elopement and emergency preparedness with safe evacuation/egress had not been identified as a QAPI concern but it would now be added.
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IRONDALE POST ACUTE in COMMERCE CITY, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COMMERCE CITY, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from IRONDALE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.