Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 South Platte Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with a history of aggressive behavior was involved in two incidents of physical abuse towards other residents. The facility failed to update the resident's care plan with new interventions and did not conduct frequent checks as an immediate intervention. This led to physical and psychosocial harm to the victims, with one resident experiencing increased anxiety and isolation. The facility's inaction in addressing the aggressive behavior and the victims' trauma contributed to the deficiency.
The facility failed to manage a resident's aggressive behavior, resulting in physical abuse towards another resident and subsequent psychosocial harm. Despite having care plans, the facility did not update interventions or address mood changes in the affected resident, neglecting their mental well-being.
The facility failed to ensure RN assessments for residents after unwitnessed falls and a resident-to-resident altercation. Two residents were assisted from the floor by an LPN and a CNA before an RN assessment, resulting in one resident sustaining a hip fracture. Another resident involved in an altercation was not assessed by an RN despite reporting pain and visible injuries.
Expired medications were found in a medication cart and storage room, including anti-itch cream, anasep gel, derma klenz wound cleanser, and aspirin. The scheduler, responsible for checking expiration dates, failed to remove these items, and the DON emphasized the importance of disposing of expired medications to prevent adverse effects.
The facility failed to maintain proper infection control practices during wound care and housekeeping. An LPN did not disinfect scissors or use a sterile applicator during wound care, and the infection preventionist used the same gauze for multiple wounds without hand hygiene between glove changes. The housekeeping supervisor also neglected hand hygiene between tasks, lacking necessary supplies. Staff interviews confirmed these lapses in protocol.
The facility failed to maintain a safe, clean, and homelike environment, with observations revealing broken floor tiles, loose kick plates, and water damage in resident rooms. Staff interviews indicated that maintenance issues were known but delayed due to awaiting approval from new ownership, and no current performance improvement plan was in place.
The facility failed to manage pain for two residents, leading to deficiencies in care. One resident experienced significant pain during wound care without adequate medication, and the facility did not update her care plan or notify her physician. Another resident's pain medication was stopped without consultation, and her care plan lacked a focus on pain management. Discrepancies in medication orders were noted, and the facility did not provide a pain management policy when requested.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, leading to physical and psychosocial harm. Resident #4, who had a history of alcohol abuse and encephalopathy, was involved in two separate incidents of physical aggression towards other residents. On 10/21/24, Resident #4 intentionally collided his wheelchair into Resident #5, causing physical injuries and increased anxiety for Resident #5. The facility did not implement additional interventions for Resident #4 following this incident to prevent further occurrences. A month later, on 11/21/24, Resident #4 was involved in another altercation with Resident #6, where he stood up from his wheelchair and grabbed Resident #6 by the shirt collar. Resident #6 pushed Resident #4 away, resulting in Resident #4 hitting his head. Despite these incidents, the facility failed to update Resident #4's care plan with new interventions in a timely manner, and there was no documentation of frequent checks being conducted as an immediate intervention after the first incident. The facility's inaction in updating care plans and implementing effective behavior interventions and monitoring for Resident #4 contributed to the repeated incidents of physical abuse. Additionally, the facility did not adequately address the psychosocial harm experienced by Resident #5, as her trauma-informed care plan was not initiated until two months after the incident, and her mood changes were not identified or addressed following the altercation.
Failure to Address Aggressive Behavior and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents, resulting in deficiencies in their mental and psychosocial well-being. Resident #4, who was admitted with diagnoses including alcohol abuse and encephalopathy, exhibited verbally aggressive and abusive behaviors towards other residents. The facility did not implement effective interventions to manage Resident #4's behaviors, leading to incidents of physical abuse towards other residents, including Resident #5. Despite having a care plan in place, the facility did not update it with new interventions following incidents of physical aggression, nor did they identify triggers or ensure the safety of other residents. Resident #5, who was a victim of physical abuse by Resident #4, experienced increased anxiety and social isolation as a result of the incident. The facility failed to thoroughly assess Resident #5 for changes in mood and behavior following the altercation. Despite documented mood changes and increased signs of depression, there was no social service progress note or changes to the care plan to address these issues. The facility also did not notify the physician or behavioral health services of these changes, further neglecting Resident #5's psychosocial needs. Interviews with staff revealed a lack of awareness and documentation regarding interventions for Resident #4's aggressive behavior. The social services director admitted to not making necessary progress notes and failing to document referrals to behavioral health services. The nursing home administrator acknowledged that the facility should have identified triggers and added more interventions to Resident #4's care plan after the first physical altercation. These oversights contributed to the ongoing issues and deficiencies in the care provided to both residents.
Failure to Ensure RN Assessments After Falls and Altercations
Penalty
Summary
The facility failed to ensure that resident assessments were conducted by qualified personnel according to each resident's written plan of care. Specifically, the facility did not have a Registered Nurse (RN) assess two residents who experienced unwitnessed falls before they were assisted from the floor. Additionally, a resident involved in a resident-to-resident physical altercation was not assessed by an RN following the incident. Resident #8, who had a history of falls and was at high risk for falling, experienced an unwitnessed fall. The incident report indicated that a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA) assisted the resident from the floor before an RN could perform an assessment. The resident was later diagnosed with a left hip fracture. Similarly, Resident #3, who was also at risk for falls, experienced an unwitnessed fall. The resident was assisted from the floor by an LPN and a CNA before an RN assessment was conducted. The resident sustained a skin tear and bruising from the fall. Resident #5 was involved in a resident-to-resident altercation where another resident collided with her wheelchair. The resident reported pain and had visible injuries, including an abrasion and redness. However, the assessment was conducted by an LPN, and no RN was called to assess the resident's injuries. The facility's policy required that an RN assess residents after incidents with potential injuries, but this was not followed in these cases.
Expired Medications Found in Storage and Carts
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards, as observed in one of two medication carts and one of two medication storage rooms. Specifically, expired medications were found in these areas, which is against the guidelines set by the United States Food and Drug Administration (USFDA) and the facility's own Medication Labeling and Storage policy. The expired items included a tube of anti-itch cream, a tube of anasep gel, a bottle of derma klenz wound cleanser, and three bottles of aspirin, all of which had passed their expiration dates. During interviews, the scheduler, who is responsible for ordering supplies and checking for expired medications, stated that she stocks the medication storage rooms weekly and checks for expired medications monthly. However, the presence of expired medications indicates a lapse in this process. The Director of Nursing (DON) confirmed that nurses are expected to check expiration dates before administering medications and dispose of expired items using a drug buster container. The failure to remove expired medications from storage and medication carts could lead to adverse effects or reduced efficacy of treatments.
Infection Control Deficiencies in Wound Care and Housekeeping
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inappropriate practices during wound care and inadequate hand hygiene by housekeeping staff. During wound care for a resident, an LPN did not disinfect scissors before using them on a clean field and applied silver cream directly to the wound bed with gloved fingers instead of using a sterile applicator. Additionally, the LPN did not disinfect the scissors before cutting clean dressings. The infection preventionist also failed to use separate gauze for cleaning multiple wounds and did not perform hand hygiene between glove changes. Housekeeping staff also did not adhere to proper hand hygiene practices. The housekeeping supervisor was observed changing gloves frequently between cleaning tasks in residents' rooms but did not perform hand hygiene after removing soiled gloves or before donning clean ones. The supervisor admitted to not having a bottle of hand sanitizer on the housekeeping cart, which contributed to the failure to perform hand hygiene. Interviews with staff revealed a lack of adherence to infection control protocols. The LPN acknowledged the oversight in not disinfecting scissors and using a sterile applicator, while the infection preventionist confirmed the need for separate gauze and proper hand hygiene. The housekeeping supervisor recognized the importance of hand hygiene but failed to maintain the necessary supplies to ensure compliance.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable homelike environment for residents in two of three hallways. Observations revealed multiple maintenance issues, including broken floor tiles, loose and broken kick plates on doors, and water damage on walls. These deficiencies were noted in several resident rooms, with one resident expressing dissatisfaction with the living conditions, comparing it to a 'cockroach motel.' The environmental services director was responsible for maintaining the facility's cleanliness and safety, but the necessary maintenance services were not facilitated. Interviews with staff revealed that the housekeeping supervisor was aware of the missing floor tiles for over a year. The maintenance supervisor acknowledged the safety concerns posed by the broken kick plates and floor tiles and mentioned that repairs were delayed due to awaiting approval from new ownership. The nursing home administrator confirmed that maintenance concerns had been previously reported but were pending approval from the new company. The facility did not have a current performance improvement plan for addressing these physical environment issues.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in their care. Resident #10, who was cognitively intact and required total assistance for transfers and toileting, experienced significant pain during wound care. Despite having a pain management care plan, the plan did not address her abdominal wounds, and her pain level was not adequately managed during wound care. Observations revealed that Resident #10 cried out in pain during wound care, and no additional pain medication was offered. Furthermore, the facility did not notify the resident's physician about the increased pain levels during wound care. Resident #12, who was also cognitively intact and required substantial assistance for transfers and toileting, experienced inadequate pain management upon readmission to the facility. The resident reported that her pain medication was stopped without consultation, and she was left with only Tylenol and ibuprofen, which did not adequately manage her pain. The comprehensive care plan for Resident #12 did not include a focus on pain management, and there was a discrepancy in the medication orders, as oxycodone was not entered into the electronic medical record despite being part of the nurse practitioner's readmission progress note. The facility's failure to manage pain effectively for these residents was compounded by the lack of a provided pain management policy when requested. Staff interviews revealed that the facility was in the process of revamping their admission process to prevent medication reconciliation errors, but at the time of the survey, these deficiencies in pain management had not been addressed, leading to significant discomfort for the residents involved.
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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 Brush
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eben Ezer Lutheran Care Center | 0.5 mi | — | 1 | 0 |
| Valley View Villa | 7.4 mi | — | 1 | 0 |
| Sterling Rehabilitation And Nursing, Llc | 33.8 mi | — | 10 | 0 |
| Devonshire Care Center | 35.7 mi | — | 2 | 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.