Grace Pointe Cont Care Sr Campus, Skilled Nursing
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
new hires and then they were retrained annually. They said the staff was retrained after the incident on 10/2/25. They said the incident was considered a fall and they did an initial set of neurological checks, but did not continue them because she did not hit her head. They said the nurses should be making the decisions about the sling size, not the CNAs. They said they were unsure if there was an official sling assessment. In regards to the first bruise with fracture, the ADON said they did not measure bruises because everyone measures them so differently. The NHA said that the notes documented by the physician and the ADON regarding the bruise occurring during a transfer on 7/17/25, were documented under assumption. The NHA said she remembered Resident #3 was at one time a stand-pivot transfer, but she had so many bad days that at some point she was moved to a sit-to-stand. The nurse practitioner (NP) was interviewed on 10/22/25 at 10:02 a.m. She said she did not think the fracture could have happened while Resident #3 was lying in bed. She said she had heard that it happened during a transfer. She said she could only think of a fracture like that happening by her leg coming into contact with something. She said
she would recommend therapy to do transfer status assessments since they were the ones who know most about body mechanics. The primary care physician (PCP) was interviewed on 10/22/25 at 11:12 a.m. He said he was called and was told about the bruise on 7/17/25. He said he saw the bruise on 7/17/25 and ordered an Xray. He said the color of the bruise was dark purple and the size was about the size of a fist, four-five inches. He said he was unsure if Resident #3 would have responded when it happened. He said
the results of the Xray showed a tibia fracture. He said the way the fracture looked it looked as if it had to have been hit laterally. He said the fracture could not have happened by rolling or moving in bed. He said it probably happened by her bumping into something. He said it most likely happened on the evening shift.
CNA #6 and RNA#1 were interviewed on 10/22/25 at 12:39 p.m., after the Hoyer lift observation (see
observations above). CNA #6 said she initially used the red sling with Resident #3, she said she thought it was a medium, but they were told to use the extra-large sling with the green border with her because it gave her more stability with her fracture. She said the DON had made the decision to use the extra-large sling. Both of the aides said that they normally tried to get the sling as far under her as possible. CNA #6 said sometimes Resident #3's position in her wheelchair caused it to be difficult to position the sling correctly. She said what made it difficult to position her sling when they transferred her earlier was there was a paper chuck covering her seat cushion and she was pushing back when they tried to lean her forward. She said the set up in the room with all the large furniture made it difficult to move the lift. She said
she should have had Resident #3's legs on the side closest to the bed. She said Resident #3 was a two-person assist with gait belt prior to her being a Hoyer lift. The ADON and the NHA were interviewed together on 10/22/25 at 1:21 p.m. The ADON said the Hoyer lift sling should support the head and should not cover the head. She said ideally the CNAs should lean the resident forward and slide the sling behind them and lean them side to side to position the sling underneath them. She said the resident's bottom should be in the hole of the split sling but should not be falling through the hole. She said the staff were updated on a resident's transfer status, when the resident was admitted and a nurse-to-nurse was done.
She said based on what the admitting nurse received in report was what the residents transfer status was.
She said the transfer status would stay the same until there was a change in condition. She said all the information went on both the nurse and CNA report sheets and whiteboards. She said the report sheets were updated daily.
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GRACE POINTE CONT CARE SR CAMPUS, SKILLED NURSING in GREELEY, 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 GREELEY, 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 GRACE POINTE CONT CARE SR CAMPUS, SKILLED NURSING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.