Highland Park Rehabilitation & Care Center
500 Geneva St, Aurora, CO 80010 · For profit - Limited Liability company · 110 certified beds · (303) 364-9311 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.0% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 4.7% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.9% | 8.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.4% | 13.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.0% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.9% | 20.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 1.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 72.6% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.2% | 20.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.6% | 12.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.85 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.87 | 1.74 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 76.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.83 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.2%CMS range 40.8–65.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 6.9–16.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 76.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 69.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.63 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 110 beds and averages 107.7 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.76 on weekdays — 15% thinner on weekends. RN hours go from 0.71 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2025-07-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#1) of three residents reviewed for accidents out of 20 sample residents. Resident #1 was admitted to the facility for skilled nursing care on 6/13/25 .The resident's care plan directed staff to utilize a mechanical lift for transfers. On 6/18/25, Resident #1 was noted to have pain to her left upper extremity and bilateral lower extremities after being lowered to the floor with the use of a mechanical lift by certified nurse aide (CNA) #1. After the resident's fall, CNA #1 and CNA #6 proceeded to assist Resident #1 into her wheelchair using the mechanical lift, prior to the resident being assessed by a registered nurse (RN) (see staff interviews below). Resident #1 was transported to the hospital on 6/18/25 where it was revealed that the resident had sustained fractures to her upper left arm (humerus) and both legs (tibia). The facility investigation after the incident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure notification to the resident representative of a significant change in the resident's physical, mental or psychosocial status for one (#11) of three residents reviewed for change of condition out of 20 sample residents.Specifically, the facility failed to notify Resident #11's representative of the resident's deteriorating wounds in a timely manner.Findings include:I. Facility policy and procedureThe Notification of Change policy, revised January 2025, was provided by the nursing home administrator (NHA) on 7/28/25 at 12:11 p.m. The policy read in pertinent part, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family members or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#6) of seven residents reviewed for abuse out of 20 sample residents were free from abuse.Specifically, the facility failed to protect Resident #6 from abuse by Resident #9.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, reviewed January 2025, was provided by the nursing home administrator (NHA) on 6/30/25 at 12:00 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will have written procedures to assist staff in identifying the different types of abuse: mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident-to resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-22 · tag F0800 — widespreadProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences. Specifically, the facility failed to ensure weekly menus were balanced and included a variety of menu items. Findings include: I. Resident interviews Resident #4 was interviewed on 5/21/25 at 11:18 a.m. Resident #4 said she wished the menu had better variety and the menu options changed more frequently. Resident #4 said lately the menu was too repetitive and there was too much chicken and pork on the menu. Resident #8 was interviewed on 5/21/25 at 3:55 p.m. Resident #8 said the menus were too repetitive. Resident #8 said the vegetable options on the menu were too repetitive. Resident #8 said there were too many vegetable blends and mixed vegetables on the menu. Resident #15 was interviewed on 5/21/25 at 4:10 p.m. Resident #15 said at times the menu was too repetitive. II. Weekly menu Four weeks of menus were provided by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two (#2 and #3) of eight residents out of 15 sample residents. Specifically, the facility failed to complete a thorough investigation after an allegation of physical abuse towards Resident #3 by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised January 2025, was provided by the nursing home administrator (NHA) on 5/21/25 at 11:30 a.m. The policy read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of property or resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure three (#19, #54 and #25) of four residents who required respiratory care received care consistent with professional standards of practice out of 34 sample residents. Specifically, the facility failed to: -Follow physician's orders to maintain, clean, sanitize and store Resident #19's continuous positive airway pressure (CPAP) mask and machine and Resident #54's bilevel positive airway pressure (BiPAP) mask and machine; and, -Rinse and store cup and mouthpiece for Resident #25's nebulizer (a small machine that turns liquid medication into a mist that can be inhaled to treat lung conditions.) Findings include I. Facility policy and procedure The CPAP/BiPAP Cleaning policy, revised 6/1/24, was provided by the director of nursing (DON) on 12/5/24 at 1:36 p.m. The policy revealed in pertinent part It is the policy of the facility to clean CPAP/BiPAP equipment with current Center for Disease Control (CDC) guidelines and manufacturer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeepers followed appropriate infection control processes when cleaning resident rooms; and, -Ensure high touch areas in resident rooms were disinfected. Findings include: I. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 11/12/24 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure: -Hair restraints were worn by staff in the main kitchen while preparing, handling, cooking and serving food for the residents: and, -Ensure fluorescent ceiling lights above areas where food was prepared, cooked, and served were covered by light shades. Findings include: I. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (2024)) retrieved from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view on 4/18/24, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair,that are designed and worn to effectively to keep their hair from contacting exposed food; clean equipment, utensils, and linens. Lights bulbs shall be shielded, coated, or otherwise shatter-resistant, in areas where there is exposed food; clean equipment, utensils, and linens. II.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-17 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure hallway ceiling light fixtures on hallways 200 and 500, and Resident #4's room were free from bugs. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated July 2019, pp. 94-95, retrieved on 4/22/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (able to transmit infectious diseases). Arthropods recovered from health-care facilities have been shown to carry a wide variety of pathogenic microorganisms. From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. Modern approaches to institutional pest…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews the facility failed to provide a comfortable and homelike environment for the residents of the facility for three out of four units. Specifically the facility failed to ensure: -Residents were provided with washcloths and hand towels; and -Room walls, furniture were properly maintained. Findings include: I. Lack of walls and furniture properly maintained A. Observations 7/9/23 at 10:30 a.m. -room [ROOM NUMBER] the window blinds were bent both forward and backward and were not effective in keeping light out of the room when closed. -room [ROOM NUMBER] the wall behind the resident ' s headboard had deep scratches and gouges approximately 12 inches long by one inch wide from the bed being lifted and lowered. -room [ROOM NUMBER] the bathroom door got stuck and was difficult to open. -room [ROOM NUMBER] the top two dresser drawers were missing. 7/11/23 at 12:15 p.m. -room [ROOM NUMBER] the dresser drawers were not aligned and falling out. 7/12/23 at approximately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-13 · tag F0676 — failed to keep up residents' daily-living abilities — patternEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice in accordance with a resident's inability to carry out activities of daily living (ADLs) for three (#68, #47 and #20) out of seven residents reviewed for ADLs of 43 sample residents. Specifically, the facility failed to provide supervision, encouragement, cueing and assistance during meals to Resident #68, Resident #47 and Resident #20. Findings include: I. Resident #68 A. Resident status Resident #68, age [AGE], was admitted on [DATE]. According to July 2023 computerized physician's orders (CPO), diagnoses included dementia, chronic kidney disease, depression and nutritional deficiency. The 4/25/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and unable to complete a brief interview for a mental status (BIMS). She required extensive assistance of one person with one-person assistance with bed mobility, personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · E2023-07-13 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observations and record review the facility failed to ensure that each resident received food that was palatable, attractive and an appetizing temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; and, -Ensure food was served at a safe and appetizing temperature. Findings include: I. Facility policy and procedure The Meal Preparation policy and procedure, revised 2021, was delivered by the nursing home administrator (NHA) on 7/12/23 at 11:15 a.m. It read in pertinent part: each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; food that is palatable, attractive, and at the proper temperature. Food is served at palatable temperatures, above 125 degrees for hot food and below 50 degrees for cold food. II. Resident interviews Resident #28 was interviewed on 7/9/23 at 10:52 a.m. The resident said the eggs were often over cooked. Resident #15 was interviewed on 7/9/23 at 10:55 a.m. The resident said his daughter brought in his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-13 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to have a thermometer and monitor temperatures for Resident #28, #15, #9, #38, #37 and #19's personal refrigerators. Findings include: I. Facility policy and procedure The Food from Outside Sources policy, dated 5/3/23, was delivered by the nursing home administrator (NHA) on 7/10/23 at 2:01 p.m. It read in pertinent part, to allow access to foods not provided by the facility and to assure foods are safe to prevent foodborne illness and to add quality to residents' life. If food is not consumed upon arrival, it may be stored in a suitable container and labeled with date, residents name and item description if needed. Resident's food stored under refrigeration shall have name, date, and expiration date of the label. Perishable food is discarded within three days from any resident refrigerator sources unless…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon an observation and interviews, the facility failed to provide a safe and sanitary environment consistent with professional standards of practice to help prevent the development and transmission of communicable disease and infections. Specifically, the facility failed to: -Ensure standard hand hygiene precautions and donning and doffing gloves were followed by staff involved in direct resident incontinent care and contact; -Clean high touch items, call button and door knobs, in resident rooms; and, -Follow the recommended surface disinfectant time for cleaning solution. Findings include: I. Lack of proper hand washing A. Facility policy and procedure The Handwashing/Hand Hygiene policy, revised August 2009, was provided by the nursing home administrator on 7/12/23 at 11:30 am. It read in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is the last step…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to provide one (#91) of two residents reviewed for dignity, out of 43 sample residents, care in a dignified, respectful and individualized manner. Specifically, on 7/11/23, Resident #91 said she did not receive her dinner meal, and the cook disagreed and refused to prepare a meal for her. Resident #91 said this made her feel unimportant and that she did not matter. Findings include: I. Facility policy and Procedure The Dignity policy, last revised in February 2021 was received on 7/12/23 from the nursing home administrator. The policy read in pertinent part, Each resident should be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self-worth and self-esteem. II. Resident #91 Resident #91, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included a history of falling, diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to implement an ongoing resident centered activities program to enhance the interest of, and support the physical, mental, and psychosocial well-being for one resident (#7) of 13 residents reviewed for activities out of 43 sample residents. Specifically, the facility failed to ensure Resident #7 was provided with meaningful, individualized activities and social engagement in accordance with the resident's functional and psychological strengths and abilities in fulfillment with the resident's plan of care. Findings include: I. Facility policy and procedure The Activity Schedule policy, revised 3/14/23, was provided by the director of nursing (DON) on 7/13/23 at 2:55 p.m. It read in pertinent part, All activities can be therapeutic, regardless of what population is being served. The community will provide daily activities that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#61) out of one reviewed for the use of the trilogy bilevel positive airway pressure (BIPAP) machine out of 43 sample residents. Specifically, the facility failed to for Resident #61: -Ensure the physician orders included settings of the Trilogy BIPAP; -Ensure the licensed nurses and certified nurse aides were trained on the system; and, -Ensure the care plan was updated to include the settings of the Trilogy Findings include: I. Resident status Resident #61, age [AGE], was readmitted on [DATE]. The July 2023 computerized physician orders (CPO) diagnoses included obstructive sleep apnea and diabetes mellitus type II. The 4/29/23 minimum data set (MDS) assessment coded the resident with no cognitive impairments with a score of 15 out of 15 for the brief interview for mental status. The resident required extensive assistance with activities of daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to effectively address the care and service needs of two (#53 and #66) of three residents reviewed for dementia care out of 43 sample residents. Specifically, the facility failed to: -Provide personalized activities programming to Resident #53 and Resident #66, who had a diagnosis of dementia; -Consistently monitor behaviors of concern including aggression toward others for Resident #53; and, -Implement personalized interventions in response to Resident #53's behaviors towards other residents. Findings include: I. Facility policy The Memory Care Program, not dated, was provided by the nursing home administrator (NHA) on [DATE]. It documented, in the pertinent part, Connections is specifically designed to provide the highest level of care for people living with all stages of Alzheimer's and dementia related diseases. We have a comprehensive, person directed approach that helps residents experience life to the fullest. We believe, persons,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure consistent behavior monitoring was conducted for target behaviors related to the use of psychotropic medications for two (#258 and #89) of five residents reviewed for medications of 43 sample residents. Specifically, the facility failed to: -Ensure staff identified triggers for the residents use of the antipsychotic medication for Resident #258 and Resident #89; -Ensure provided non-pharmacological interventions for Resident #258 and Resident #89; and, -Ensure the facility developed specific target behaviors and ensure the behavior monitoring forms consistently matched the target behaviors were documented for Resident #258 and Resident #89. Findings include: I. Resident #258 A. Resident status Resident #258, age [AGE], was admitted on [DATE]. According to July 2023 computerized physician's orders (CPO), diagnoses included vascular dementia and depression. According to the 6/15/23 minimum data set (MDS) assessment revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation the facility failed to provide routine dental services to one (#44) of three residents out of 43 sample residents. Specifically, the facility failed to provide dental services to Resident #44. Finding include: I. Facility policy and procedure The Ancillary Services-Dental, Vision, Audiology, Podiatry policy and procedure, dated 8/19/14, was delivered by the nursing home administrator (NHA) on 7/18/23 at 1:01 p.m. it read in pertinent part ancillary services, including but not limited to, dental, vision, audiology, and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident / responsible family member's request and as needed. Any resident needing or requesting ancillary services such as dental will have their needs met timely. The facility will keep available a provider for ancillary services and / or assist the resident with utilizing the provider of their choice. Social services/designee will be responsible for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-05-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, document review, and policy review, the facility failed to ensure one of one facility kitchen was maintained in accordance with professional food service/safety standards. This deficient practice had the potential to affect all 93 residents residing in the facility. Specifically, the facility failed to ensure dietary staff: - regularly cleaned soiled areas in the kitchen; - dated and discarded perishable food appropriately; - regularly measured and recorded food temperatures; and - maintained freezer temperatures at or below zero degrees Fahrenheit (F). Findings include: Review of the facility policy titled, Subject: Food Wholesomeness, dated as reviewed March 2021, revealed, Kitchen and serving areas are clean at all times. A cleaning schedule is followed and initialed when tasks are one. Food temperatures are taken for serving at every meal and at the point when a resident is served a meal on a regular basis. Rules and Regulations for Retail Food Service Establishments are used as a reference for food service operations. 3. Cold foods are kept…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-12-05 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Findings include: I. Failure to have staffing hours posted Observations in the facility on 12/2/24 at 8:00 a.m. revealed there were no staff postings including hours worked posted in the facility Observations in the facility on 12/3/24 at 12:40 p.m. revealed there were no staff postings including hours worked posted in the facility. Observations in the facility on 12/4/24 at 4:40 p.m. revealed there were no staff posting including hours worked posted in the facility. II. Staff interviews The regional clinical coordinator (RCC) was interviewed on 12/4/24 at 4:43 p.m The RCC said the facility did not have the staffing posted. The director of nursing (DON) was interviewed on 12/4/24 at 4:45 p.m The DON said she had not seen daily staffing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SWEETWATER CARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.4 | +2.6 vs chain |
| Health inspection | 4 of 5 | 2.1 | +1.9 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 5 of 5 | 3.9 | +1.1 vs chain |
The other 7 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SWEETWATER CARE RESOURCE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 06/01/2024 |
| CHESLEY, AARON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | 48% | since 06/01/2024 |
| GAMETT, JAMES | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2024 |
| BOUZIDA, NABIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2024 |
| REDDY, VIKAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2024 |
| GAMETT, SHAUNA | Individual | TRUSTEE OF THE SNF | — | since 06/01/2024 |
CMS files one row per role, so the 16 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $542K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Colorado Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 065176. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.