Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Irondale Post Acute during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a feeding tube did not receive prescribed enteral nutrition for several days after admission because the hospital discharge orders were not entered into the facility's electronic system. Staff interviews confirmed that the admitting nurse failed to verify and transcribe the physician's orders, resulting in the resident missing required tube feeding.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was left unsupervised for several hours after exhibiting agitation and distress, resulting in the resident eloping from the secured unit by bypassing window safety mechanisms and climbing over a gate. Staff did not implement individualized interventions or frequent checks as required by the care plan, and documentation showed a lack of specific strategies to address elopement risk. Additionally, the facility lacked posted evacuation routes, and the primary emergency egress was padlocked with staff unaware of how to access it, leaving all residents at risk in the event of an emergency.
The facility's QAPI committee failed to identify and address critical issues related to resident elopement and emergency preparedness, resulting in immediate jeopardy situations where serious adverse outcomes were likely. Despite regular meetings and a written policy, the committee did not prioritize these high-risk areas until after surveyors identified the deficiencies, and previous similar incidents had occurred.
A resident with bilateral below-the-knee amputations and multiple comorbidities was not properly secured in a facility van during transport, leading to a fall and severe injuries including spinal fractures and a brain bleed. The van driver failed to anchor the wheelchair and apply restraints, and another resident reported similar lapses by the same driver. Staff interviews confirmed that proper securement procedures were not followed.
A resident at a LTC facility, identified as a high fall risk, sustained a fall resulting in a hip fracture that went unreported and untreated for six days. Despite the presence of a CNA and an LPN, the fall was not reported, and the resident was moved without proper assessment. The resident exhibited signs of a change in condition, including lethargy and bruising, which were documented but not immediately linked to the fall. The fracture was eventually discovered through an x-ray, highlighting the facility's failure to ensure timely reporting and assessment.
Failure to Provide Physician-Ordered Tube Feeding Upon Admission
Penalty
Summary
A deficiency occurred when a resident with a feeding tube did not receive tube feeding administration as ordered by the physician. Upon admission from the hospital, the resident had diagnoses including pneumonia, muscle weakness, acute respiratory failure, dysphagia, protein calorie malnutrition, and cerebral infarction. The resident was assessed as having mild cognitive impairment and required assistance with daily activities. The care plan specified the need for tube feedings due to swallowing difficulties, with interventions including elevating the head of the bed, providing tube feeding and water flushes per physician orders, and monitoring nutritional intake. Despite these documented needs, the physician's orders for enteral feeding were not entered into the resident's computerized physician orders (CPO) until five days after admission. The hospital discharge summary included specific instructions for continuous enteral feeding and water flushes, but there was no documentation in the electronic medical record (EMR) indicating that these orders were followed from the time of admission until they were entered into the CPO. As a result, the resident did not receive the prescribed tube feeding during this period. Interviews with facility staff confirmed that the admitting nurse did not transcribe or verify the hospital discharge orders with the facility physician upon admission. The registered dietitian and regional clinical resource both stated that it was the responsibility of the admitting nurse to ensure all physician orders, including those for tube feeding, were entered and initiated. The failure to do so resulted in the resident missing necessary nutritional support as ordered by the physician.
Failure to Prevent Elopement and Maintain Safe Evacuation Routes
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically in the case of a resident with a high risk for elopement. The resident, who had a history of impulsive behaviors, cognitive impairment, and multiple medical conditions including bipolar disorder, chronic heart failure, and a traumatic brain injury, was admitted to the secured unit after being assessed as high risk for elopement. Despite the resident's repeated exit-seeking behaviors, verbalizations of wanting to leave, and documented behavioral episodes such as refusing care, throwing food, and expressing distress, the facility did not implement or follow individualized interventions for supervision and monitoring as outlined in the care plan. On the day of the incident, the resident exhibited escalating agitation, refused his meal, and attempted to contact family without success. Staff failed to provide increased oversight or frequent checks during this period, and the resident was left unmonitored for approximately four hours before being discovered missing. The facility's investigation revealed that the resident eloped by overriding the window safety mechanism and climbing over a gate in the secured courtyard. The absence of consistent monitoring and failure to respond to the resident's behavioral cues resulted in the resident being missing for approximately 46 hours before being located at a homeless shelter. Documentation and staff interviews confirmed that the care plan lacked specific interventions to address the risk of elopement and that staff did not consistently implement the existing interventions. The facility's records also showed a pattern of the resident expressing a desire to leave, refusing medications, and exhibiting aggressive or impulsive behaviors, yet these were not met with appropriate or timely interventions to ensure his safety. Additionally, the facility did not have an effective evacuation plan in place. Observations showed that evacuation routes were not clearly posted, and the primary emergency egress for the secured unit was padlocked, with staff unaware of the key's location. Staff interviews indicated a lack of training and understanding of evacuation procedures, and the physical barrier of the padlocked gate prevented accessible egress in an emergency. These failures created a hazardous environment for all residents, as staff were not prepared to safely evacuate residents in the event of an emergency, and the environment was not adequately maintained to prevent accidents or ensure resident safety.
Removal Plan
- The padlock and the latch on the outdoor fenced storage areas were removed by the NHA.
- The facility map of the egress routes were posted by the life safety/maintenance resource for all halls.
- The facility was toured by the life safety resource to identify and ensure all egress exits were unlocked and accessible.
- All residents were reviewed by the director of nursing (DON) and clinical resource for elopement risk and care plans were updated as needed.
- Education with the NHA and the IDT (interdisciplinary team) initiated by clinical resource on keeping facility egress routes unlocked and accessible.
- All staff education initiated by DON/designee on specific evacuation routes, keeping egress exit for emergency exits for the secured unit unlocked and accessible, the codes for the exit doors and the facility evacuation map postings.
- Education on the emergency operations procedure quick reference guide initiated which showed initial employee expectations and responsibilities.
- Window security devices will continue to be monitored until window alarms are in place.
- Window alarm installation to be initiated for the secured unit.
- All staff were to be educated on evacuation procedures during orientation.
- Staff education initiated by the DON/designee on the need for safety checks and monitoring during a behavioral episode to prevent further occurrences and where to locate resident elopement care plans.
- Staff were educated that although residents may request to be left alone or to have their door closed, it does not eliminate the facility's obligation to ensure the safety of the resident; staff needs to verify that the resident was safe and present.
- Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks.
- Behavioral episodes could include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing.
- The facility will be completing a headcount on the secured unit every two hours by floor nurse, nursing management, or designee.
- Headcount to be completed on paper audit form for a minimum of 12 weeks or until substantial compliance has been achieved.
- The DON, or designee, will complete random audits three times per week for 12 consecutive weeks.
- The audit will include: Staff interview: Does staff member know evacuation route? Observation: All egress routes are unlocked and available in case of emergency? Staff interview: Does staff know to provide safety checks and increased monitoring during a resident behavioral episode? Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks. Behavioral episodes can include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing. Staff interview: Does staff know how to access the resident's elopement care plan? Staff interview: Does staff know the codes to the exit doors? Additional comments and/or interventions if issues noted on audit form.
- Audit records will be reviewed by the risk management/quality assurance committee monthly until such time consistent substantial compliance has been achieved as determined by the committee.
Failure to Identify and Address Elopement and Emergency Preparedness in QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to accident and hazard prevention. The QAPI committee did not identify or address issues involving resident elopement and emergency preparedness, including the lack of supervision necessary to prevent a resident from leaving the facility unsupervised and the absence of a system to ensure staff followed emergency evacuation procedures. These deficiencies resulted in situations that rose to the level of immediate jeopardy, where a serious adverse outcome was likely. Record review revealed that the facility had a history of similar deficiencies, with previous citations for failure to prevent accidents and hazards, including falls and elopement. Despite having a QAPI policy and procedure in place, the committee did not recognize or prioritize these high-risk areas for process improvement. The facility's QAPI meetings focused on standard issues such as falls, infections, and hospitalizations, but did not address elopement or emergency egress concerns until after they were identified by surveyors. Interviews with facility leadership, including the medical director, NHA, and DON, confirmed that the QAPI committee met regularly and included required members, but had not previously identified elopement or emergency preparedness as areas needing attention. The medical director had not provided recent education to staff or reviewed policies related to these issues. The lack of systematic identification and prioritization of these high-risk concerns contributed to the facility's failure to prevent immediate jeopardy situations related to resident safety.
Failure to Properly Secure Wheelchair During Transport Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a wheelchair-bound resident, who was dependent on staff for mobility and positioning due to bilateral below-the-knee amputations and other significant medical conditions, was not properly secured during transportation in the facility's van. The van driver failed to anchor the resident's wheelchair and did not apply the necessary restraints. As a result, when the van accelerated, the wheelchair tipped backward, causing the resident to fall onto the floor with the wheelchair landing on top of her. The incident resulted in the resident sustaining multiple serious injuries, including fractures of the cervical and thoracic vertebrae, multiple rib fractures, an epidural hemorrhage, and significant pain, requiring hospitalization in the ICU. Interviews and record reviews confirmed that the resident reported not feeling properly secured in the van and recounted that the driver had previously driven erratically. Another resident also reported that the same van driver had not anchored her wheelchair or applied seatbelts during transportation. Staff interviews revealed that proper procedures for securing wheelchairs included anchoring at four points and using both a lap seatbelt and a shoulder strap, but these procedures were not followed by the van driver involved in the incident. The facility's investigation noted that the van and its equipment were inspected and found to be functioning properly, indicating that the failure was due to staff action rather than equipment malfunction. The van driver was unable to confirm whether the wheelchair had been anchored prior to departure, and the facility was unable to determine how the incident occurred if the wheelchair had been properly secured. The resident required a rigid cervical collar and additional support following the incident, and her care plan was updated to reflect her new needs.
Failure to Report and Assess Fall Leads to Delayed Treatment
Penalty
Summary
The facility failed to ensure that a resident, identified as a high fall risk, remained free from accidents. The resident sustained a fall on September 6, 2024, which resulted in a hip fracture that went unidentified until September 12, 2024. The fall was not reported by the staff present at the time, leading to a delay in the identification and treatment of the injury. The resident, who had severe impairment for daily decision-making and required supervision for safety with transfers, was found to have fallen in the doorway of her room. Despite the presence of a CNA and an LPN, the fall was not reported, and the resident was moved without a proper assessment for injuries. The resident exhibited signs of a change in condition, including lethargy, weakness, and bruising, which were documented in the days following the fall but were not immediately linked to the fall incident. The facility's failure to report and assess the fall resulted in the resident not receiving timely medical attention for her hip fracture. The resident's condition deteriorated over several days, with increased bruising and swelling observed, leading to the eventual discovery of the fracture through an x-ray. The lack of immediate reporting and assessment by the staff present at the time of the fall contributed to the delay in treatment and the resident's prolonged discomfort.
Removal Plan
- A thorough investigation of the incident was conducted.
- The facility reviewed the camera footage which revealed Resident #1 sustained a fall.
- CNA #3 and LPN #2 were identified in the video and interviewed.
- LPN #2 denied knowing anything about Resident #1's fall and was terminated.
- CNA #3 verified Resident #1 sustained a fall.
- All of the nursing staff were educated by the assistant director of nursing related to the facility fall policy, reporting a fall and documenting a fall.
- The facility continued to hold Quality Assurance and Performance Improvement (QAPI) meetings to address concerns.
- The facility reviewed their current fall policy to ensure appropriate procedures were in place to prevent falls/potential harm and reporting a fall.
- All staff were re-educated on the fall policy and procedure.
- All staff that were present at the time of the investigation were provided further education.
- The DON would ensure all newly hired staff would receive education on the fall policy.
- The education given included identifying neglect, reporting a fall, RN assessment for injuries, neurological checks if there was a head injury or the fall was unwitnessed, and documenting the fall.
- The facility would review falls and discuss them in the monthly Quality Assurance and Performance Improvement (QAPI) meeting for three months.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Commerce City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgeview Post Acute | 1.3 mi | — | 5 | 1 |
| City Scape Rehabilitation & Care Center Llc | 4.4 mi | — | 0 | 0 |
| Thornton Care Center | 4.8 mi | — | 0 | 0 |
| Villas At Sunny Acres, The | 4.9 mi | — | 1 | 0 |
| City Park Healthcare And Rehabilitation Center | 6.1 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.