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The Springs At St. Andrews Village

2670 S Abilene St, Aurora, CO 80014 · For profit - Corporation · 58 certified beds · (303) 695-9300 Medicare only — no Medicaid

Call the home — (303) 695-9300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$14,220 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,220 in federal fines (most recent 2026-03-26)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
14001 E Iliff Ave · (303) 996-1020 · Call to confirm hours
Pharmacy
14001 E Iliff Ave Ste 200 · (720) 669-4567 · Call to confirm hours
Grocery
13697 E Iliff Ave · (303) 873-7035 · Call to confirm hours
Park
14001 E Iliff Ave · (303) 297-2757 · Typically dawn to dusk
Place of worship

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 improved from 3 to 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.3%13.4%15.4%better
Long-stay residents who lose too much weight5.3%4.7%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection2.4%1.4%2.0%worse
Long-stay residents with depressive symptoms8.6%8.8%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.2%3.4%3.3%better
Long-stay residents whose ability to walk worsened22.8%13.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication9.2%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.7%95.3%typical
Long-stay residents with pressure ulcers0.8%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control16.3%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.5%20.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.6%1.4%better
Short-stay residents given the seasonal flu vaccine94.8%75.6%79.4%better
Short-stay residents rehospitalized after admission13.4%20.3%22.6%better
Short-stay residents with an outpatient ER visit4.8%12.1%12.0%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.

63.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 91 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.2%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
70.1%U.S. median 56.6%
Met the expected recovery
1.60U.S. median 0.31
Therapy hours / resident / day
0.68hours / resident / day
Physical therapy
0.57hours / resident / day
Occupational therapy
0.35hours / resident / day
Speech therapy

Met the expected recovery: 70.1% 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 77 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 1.60 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.2%CMS range 53.1–72.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 6.1–13.410.7%Oct 2022–Sep 2024no 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 discharge70.1%56.6%Oct 2024–Sep 2025CMS 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 discharge61.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge70.1%50.0%Oct 2024–Sep 2025CMS 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 identified96.8%98.7%Oct 2024–Sep 2025CMS 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 setting98.4%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.4–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS 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

0.60
RN hours/ resident / day
0.93
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.48
RN hoursweekends
60.0%
Total nursing turnover
69.2%
RN turnover

How full it usually is: this home is certified for 58 beds and averages 54.3 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.20 hrs/resident/day on weekends vs 3.82 on weekdays — 16% thinner on weekends. RN hours go from 0.65 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above 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

10
deficiencies at the latest standard inspection (2026-03-26)
5
at the previous standard inspection (2024-03-27)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2026-03-26 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#74 and #71) of five residents reviewed for pain management out of 32 sample residents. Resident #74 was admitted to the facility from the hospital on 3/22/26, after treatment for sepsis (life threatening condition) from a vertebral (spinal) infection resulting in severe pain in her spine. After the resident's admission to the facility, the facility failed to ensure the resident's prescription for oxycodone was sent to the pharmacy timely so the pain medication could be received and administered. The facility's failure to send the resident's prescription to the pharmacy in a timely manner, resulted in the resident not receiving the narcotic pain medication for 21 hours after leaving the hospital, resulting in severe back pain for Resident #74.Additionally, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-26 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 proper storage of medications for one of four medication storage rooms and two of four medication storage carts.Specifically, the facility failed to:-Ensure eye drops were dated with the date they were opened;-Ensure medications were contained in the original packaging; and,-Ensure expired medical supplies were discarded.Findings include:I. Professional referenceAccording to manufacturer Allergan's Ophthalmic Medication Beyond-Use Date Guide, April 2024, retrieved on 3/30/26 from https://www.hdrxservices.com/Ophthalmic-Medication-Beyond-Use-Date-Guide-Apr-2024, Thera Tears eye drops should be discarded 90 days from opening.According to manufacturer Nephron Pharmaceutical's, Beyond-Use Date, 2026, retrieved on 3/30/26 from https://nephronpharm.com/products/ipratropium-bromide-05-mg-and-albuterol-sulfate-3-mg, Vials should be protected from light before use, therefore, keep unused vials in the foil pouch or carton. Vials should be…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for three (#19, #74 and #75) of 10 residents reviewed for dignity out of 32 sample residents. Specifically, the facility failed to ensure Resident #19, Resident #74 and Resident #75 had the right to a dignified existence by being provided privacy in their personal bathrooms.Findings include:I. Resident #19A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included stroke, unspecified dementia, anemia and hypertension.The 1/26/26 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident required partial staff assistance for transferring and toileting. She used a wheelchair 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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, record review and interviews, the facility failed to ensure that the residents had a safe, clean, comfortable, and homelike environment for three out of 12 rooms. Specifically, the facility failed to ensure the facility's process of reporting and responding to repairs in the resident's rooms was being utilized to maintain three damaged closets in Resident #8, Resident #74, and Resident #33's rooms. Findings include:I. Observations and staff interviewResident #8's room was observed on 3/23/26 at 9:13 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #33's room was observed on 3/23/26 at 9:20 a.m. The hinge holding the resident's closet door to the frame was detached from the frame.Resident #74's room was observed on 3/23/26 at 11:45 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #8's room was observed again…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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 (#30, #55 and #71) of eight residents received treatment and care in accordance with professional standards of practice out of 32 sample residents.Specifically, the facility failed to:-Ensure physician's orders for post-void residual measurements (PVR - measures the amount of urine remaining in the bladder immediately after urination) were followed for Resident #71;-Ensure physician's orders were in place for a wound dressing for Resident #55; and,-Ensure Resident #30 received wound prevention care in accordance with the physician's orders.Findings include: I. Failed to ensure physician's orders for PVRs were followed for Resident #71 A. Resident status Resident #71, age [AGE], was admitted on [DATE] and discharged to the hospital on 1/14/26. According to the January 2026 computerized physician orders (CPO), diagnoses included need for assistance with personal care, cognitive communication deficits, acute kidney failure and…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 13.33%, or four errors out of 30 opportunities for error.Findings include:I. Professional referenceAccording to Stat Pearls Nursing Rights of Medication Administration, 9/4/23, retrieved on 3/30/26 from https://www.ncbi.nlm.nih.gov/books/NBK560654, Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration.-Right patient;-Right drug;-Right route;-Right time; and,-Right dose.II. Facility policy and procedureThe Medication Administration policy and procedure, reviewed January 2022, was provided by the director of nursing (DON)…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 three (#74, #43 and #55) of eight residents reviewed for medication management were free from significant medication errors out of 32 sample residents.Specifically, the facility failed to:-Ensure Resident #74 received scheduled intravenous (IV) antibiotics as ordered; and, -Ensure Resident's #43 and #55's blood pressure medications were administered or held per physician ordered parameters. Findings include: I. Failed to ensure Resident #74 received scheduled IV antibiotics as ordered A. Professional reference According to Vancomycin Hub 2021, retrieved on 3/31/26 from https://doseme-rx.com/vancomycin, Keeping IV vancomycin and piperacillin-tazobactam (Zosyn) on a strict routine schedule is critical to maintain therapeutic efficacy against severe infections, prevent the development of drug-resistant bacteria, and manage the increased risk of kidney injury (Acute Kidney Injury - AKI) associated with their combined use. Because both drugs are…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition.Specifically the facility failed to ensure one of three washing machines in the facility's laundry room was in appropriate operational condition.Findings include:I. Observations On 3/25/26 at 8:50 a.m. an observation of the facility's laundry room revealed the following:Behind washing machine #1, four floor tiles were detached with water underneath them. A portable blower (industrial dryer) was set up behind washing machine #1 and pointed towards the detached tiles.Behind washing machine #3 was a puddle of water underneath a supply hose. A rolled up blanket was tucked to the left side of washing machine #3 and another blanket was tucked in the front of washing machine #3. Underneath the blankets, water was observed.II. Staff interviewsThe laundry aide was interviewed on 3/25/26 at 9:00 a.m. The laundry aide said she had worked at the facility in the laundry room for seven months. She said the leak behind the washing machines had been going on the entire time…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 provide a safe, sanitary, functional and comfortable environment for the residents. Specifically the facility failed to:-Ensure one of four resident shower rooms was free of deterioration and water damage and had a properly operational shower head;-Ensure resident room corridors were free of deterioration and water damage;-Ensure one of 12 resident rooms had a properly operational sink faucet; and, -Ensure two of 12 resident personal bathrooms were free of deterioration and water damage.Findings include:I. Failure to ensure one of four resident shower rooms was free of deterioration and water damage and had a properly operational shower head A. Observations On 3/23/25 at 9:12 a.m., the facility's [NAME] One shower room was observed. The shower room had four 12 by12 inch tiles on the lowest part of the shower wall, held to the wall with six strips of vertical duck tape. The tile closest to the exit door had a gap of one half an inch with a visible black…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0923 — isolated
    Have enough outside ventilation via a window or mechanical ventilation, or both.
    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 ensure adequate outside ventilation by means of windows, or mechanical ventilation for three out of 12 residents' personal bathrooms. Specifically, the facility failed to ensure ventilation fans were kept operational in the resident personal bathrooms.Findings include:I. Professional referenceAccording to the United States (U.S.) Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021 retrieved on 3/30/26 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and well-being of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-27 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training to ensure continued competence. Specifically, the facility failed to ensure 23 of 24 CNAs received 12 hours of annual training. Findings include: I. Facility policy and procedure The In-Service Training policy, revised August 2022, was provided by the executive director (ED) on 3/27/24 at 12:25 p.m. It documented in pertinent part, The primary objective of the in-service training was to ensure that staff were able to interact in a manner that enhanced the resident's quality of life and quality of care and could demonstrate competence in the topic areas of the training. II. Training review CNAs were reviewed for the required annual 12 hours of continued education units (CEUs). -Training records revealed only one out of 24 CNAs had completed the required training. III. Staff interviews The human resources director (HRD) was interviewed on 3/27/24 at 10:45 a.m. The HRD said the facility did not employ a staff development…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2024-03-27 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 (#25) of five residents out of 19 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to administer medications in a timely manner per the physician orders for Resident #25. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-27 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the outcome of the reviews for three out of five CNAs reviewed for annual reviews and training. Specifically, failed to provide performance reviews annually and training based on the outcome of the individual reviews for CNA #1, CNA #2 and CNA #3. Findings include: I. Facility policy and procedure The Performance Evaluations policy, revised September 2020, was provided by the executive director (ED) on 3/27/24 at 12:27 p.m. It documented in pertinent part, The job performance of each employee shall be reviewed and evaluated at least annually. Performance evaluations may be used in determining employee promotion, shift/position transfers, demotion, terminations, wage increases and to improve the quality of the employee's work performance. The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (further training) and goals. II. Record review 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 ensure medications and biologicals were stored and labeled properly in two of three medication storage rooms and one of three medication carts. Specifically the facility failed to: -Ensure expired medications were not stored with current medications in the medication storage rooms; -Ensure medications were stored at correct temperatures in medication storage refrigerators; -Ensure medications were not stored in a dormitory style refrigerator/freezer combination; and, -Ensure used medication vials were not stored in the medication cart. Findings include: I. Professional reference According to the Vaccine Storage and Temperature Monitoring Equipment (January 2023), retrieved on 3/18/24 from https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, It is important the facility has proper storage and monitoring equipment that was set up correctly, maintained appropriately and repaired as needed. The equipment protects patients…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 disease and infection for one of two units. Specifically, the facility failed to: -Ensure resident rooms and bathrooms were cleaned in a sanitary manner; -Ensure surface disinfectants were used for the appropriate dwell time (amount of time surface must remain visibly wet); -Ensure appropriate hand hygiene was performed by housekeeping staff; and, -Ensure high touch surfaces were cleaned. Findings include: I. Professional reference According to the Environmental Cleaning procedures (reviewed 5/4/23) retrieved on 3/28/24 from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, documented in part, Common high touch surfaces include: sink handles, bedside tables, call bells, door knobs, and light switches. High touch surfaces and floors should be cleaned at least once daily (24…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-15 · tag F0580 — failed to tell family and doctor about changes — pattern
    Immediately 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 immediate physician notification for one (#122) of three residents reviewed out of 26 sample residents. Specifically the facility failed to ensure the physician was notified of Resident #122's high blood sugar/glucose level readings that were out of physician ordered parameters. Findings include: I. Facility policy The Administering Medications policy and procedure, dated 2022, was provided by the director of nursing (DON) 12/14/22 at 2:49 p.m. It read in pertinent part, Medications shall be administered in a safe and timely manner, and as prescribed. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-15 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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 treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#9) of three residents reviewed for quality of care out of 26 sample residents. Specifically, the facility failed to follow physician orders for Resident #9: -Humaglog solution (insulin) was not administered although the physician orders documented to administer if the fasting blood glucose was greater than 180; and, -Follow the physician orders six times when the blood sugar/glucose level readings were out of physician ordered parameters. Findings include: I. Facility policy The Administering Medications policy and procedure, dated 2022, was provided by the director of nursing (DON) 12/14/22 at 2:49 p.m. It read in pertinent part, Medications shall be administered in a safe and timely manner, and as prescribed. II. Resident #9 A. Resident status Resident #9, age [AGE], was admitted initially on 7/18/22, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to establish and maintain infection control designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically the facility failed to: -Ensure proper hand hygiene was performed between residents during medication administration; and, -Ensure multiple use medical equipment was sanitized between residents. Findings include: I. Professional reference The Disinfection of Medical Equipment, updated 5/24/19, retrieved on 12/21/22, from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, documented in part. Equipment; scissors, hemostats, clamps, blood pressure cuffs, stethoscopes should be disinfected with an EPA (Environmental Protection Agency)-registered disinfectant unless the item is visibly contaminated with blood; in that case a tuberculocidal agent (or a disinfectant with specific label claims for HBV and HIV) or a 1:100 dilution of a hypochlorite solution (500-600 ppm free…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-15 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    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 provide ostomy care to one resident (#122) of one resident reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure physician orders were in place to provide colostomy care for Resident #122; and, -Ensure there was a comprehensive care plan for colostomy care. Findings include: I. Facility policy The Colostomy/Ileostomy Care policy and procedure, dated 2022, was provided by the director of nursing (DON) on 12/14/22 at 2:45 p.m. The policy read in pertinent part, The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review the resident's care plan to assess for any special needs of the resident. The following information may be recorded in the resident's medical record: the date and time the colostomy/ileostomy care was provided; the name and title of the individual(s) who provided the colostomy/ileostomy care; any breaks in resident's skin, signs of…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#9) of three residents reviewed for unnecessary medication out of 26 sample residents. Specifically, the facility failed to: -Track hours of sleep to evaluate the effectiveness of an antidepressant (Trazodone) being utilized as a hypnotic for the diagnosis of insomnia for Residents #9; -Have a physician's order to track and monitor hours of sleep for Resident #9; and, -Have non-pharmacological interventions on plan of care for insomnia for Resident #9. Findings include: I. Professional reference Davis's Drug Guide for Nurses Handbook seventeenth edition, copyright 2021, Vallerand and Sanoski, Philadelphia, PA, pp. 1233-1235. Read in part: Trazodone-classification: antidepressant. Indications: Major depression. Unlabeled use: Insomnia. Side effects: drowsiness most frequently, suicidal thoughts, confusion, dizziness and fatigue. Assess mental status, orientation, mood, and…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 drug and biologics were labeled and stored correctly in one of three units. Specifically the facility failed to: -Ensure narcotics were stored properly; and, -Ensure opened vial of influenza vaccines were dated upon opening. Findings Include: I. Professional reference According to the Afluria package insert, retrieved 12/19/22 from: https://www.fda.gov/media/81559/download, Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. II. Facility policy and procedures The Controlled Substance policy, undated, received from the director of nursing (DON) on 12/14/22 at 2:49 p.m., revealed in pertinent part, only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule two controlled drugs on premises. Controlled substances must be counted upon delivery by both the receiving nurse and the delivery person and both individuals must sign the controlled substance record. Controlled substances must be stored in a locked container, separate from…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,220 in federal fines across 1 penalty.

  • $14,220 — penalty dated 2026-03-26

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 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 →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 1 of 52.7-1.7 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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 / managerTypeRoleSince
JORGENSEN, DAVIDIndividualCORPORATE DIRECTORsince 02/05/2024
BURNAM, SOONIndividualCORPORATE OFFICERsince 02/05/2024
DUNYON, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 02/05/2024
FITCH, CRAIGIndividualCORPORATE OFFICERsince 02/05/2024

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$6.5M
Net patient revenuemost recent cost report
-10.6%
Operating marginrevenue minus expenses
$349K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 17%Other / private 83%

This home reported $349K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$656per resident / day
operating cost
$19,938per month
≈ monthly operating cost
$593per day
avg. revenue, all payers

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

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Colorado Medicaid page for homes that do.

Typical monthly cost in Colorado
$10,159/mo
Nursing home (semi-private)
$12,182/mo
Nursing home (private)
$6,584/mo
Assisted living

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 065388. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.

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