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Canon Lodge Care Center

905 Harding Ave, Canon City, CO 81212 · For profit - Corporation · 60 certified beds · (719) 275-4106 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseResident-funds citation (F0565)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 18% of its spending goes to commonly-owned related companies

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 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
602 Yale Pl · (719) 275-2301 · Call to confirm hours
Pharmacy
1703 Fremont Dr · (719) 275-3319 · Call to confirm hours
Grocery
1501 Central Ave · (719) 275-4038 · Call to confirm hours
Park
39 Mile Rd · 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 4 of 5
Long-stay residentspeople who live here 4 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 3 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 rating3★
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 increased8.6%13.4%15.4%better
Long-stay residents who lose too much weight7.1%4.7%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection1.7%1.4%2.0%better
Long-stay residents with depressive symptoms5.7%8.8%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.8%3.4%3.3%better
Long-stay residents whose ability to walk worsened15.3%13.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication6.2%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.7%95.3%typical
Long-stay residents with pressure ulcers2.9%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control25.8%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table25.0%20.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.6%1.4%better
Long-stay hospitalizations per 1,000 resident days1.231.381.67better
Long-stay outpatient ER visits per 1,000 resident days2.751.741.80worse

§ 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.

55.2% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.2%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
0.37U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.2%CMS range 47.6–63.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.3–14.510.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 3.4–16.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 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

1.12
RN hours/ resident / day
0.33
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.56
Total nurse hours/ resident / day
0.77
RN hoursweekends
51.2%
Total nursing turnover
46.2%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 35.0 residents a day — about 58% occupied, or roughly 25 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.12 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 3.19 hrs/resident/day on weekends vs 3.71 on weekdays — 14% thinner on weekends. RN hours go from 1.27 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

7
deficiencies at the latest standard inspection (2025-08-13)
8
at the previous standard inspection (2023-09-28)

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.

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · E2025-08-13 · 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

    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 and to help prevent the development of transmission of infectious disease.Specifically the facility failed to:-Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms;-Ensure housekeeping staff changed the mop head in a multiple resident room; and,-Ensure enhanced barrier precautions (EBP) were followed. Findings include: I. Housekeeping failures A. Facility policy and procedure The Daily Room Cleaning policy, revised 2/24/22, was provided by the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It read in pertinent part, The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean and sanitary environment and reduce the potential for nosocomial infections. B. Observations During a continuous observation on 8/13/25, beginning at 9:01 a.m.…

    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 · D2025-08-13 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 consent was obtained for the use of psychotropic medication for one (#26) of five residents reviewed for unnecessary medications out of 28 sample residents. Specifically, the facility failed to ensure Resident #26's responsible party was informed of an increase to psychotropic medications. Findings include: I. Facility policy and procedureThe Resident Rights facility policy and procedure, revised November 2016, was provided by the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It revealed in pertinent part, A facility must immediately inform the resident; consult with the resident`s physician; and notify, consistent with his or her authority, the resident representative(s) when there is a need to alter treatment.II. Resident #26A. Resident statusResident #26, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnosis included dementia without behavioral disturbance, psychotic…

    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 before2025-08-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 (#8) of three residents reviewed for abuse out of 28 sample residents were free from abuse.Specifically, the facility failed to protect Resident #8 from physical abuse by Resident #22.Findings include:I. Facility policy and procedureThe Abuse Prevention policy, reviewed on 5/6/25, was received from the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It revealed in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-13 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 assess, arrange, and document discharge services for one (#32) of one resident reviewed for discharges out of 28 sample residents.Specifically the facility failed to provide Resident #32 with a bed hold policy at the time of the resident's transfer to the hospital.Findings include:I. Facility policy and procedureThe Area of Focus: Discharge Process and Bed Holds policy and procedure, revised 11/19/24, was received from the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It revealed in pertinent part, Transfers or discharges include movement of a resident to a bed outside of the certified facility. Bed hold: holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. Notice before transfer: before the facility transfers the resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for one (#14) of two residents reviewed out of 28 sample residents. Specifically, the facility failed to ensure a safe transfer was performed with Resident #14 who was dependent on staff. Findings include: I. Facility policy and procedureThe Activities of Daily Living policy and procedure, revised 2/12/24 was provided by the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It read in pertinent part, Utilize appropriate safety measures and any necessary equipment to maintain resident safety.The Limited Lift Program policy and procedure, revised 2/20/24, was provided by the NHA on 8/14/25 at 1:15 p.m. It read in pertinent part, The facility will assess residents for the need for assistance with transfer activities, mobility or repositioning utilizing a validated mobility assessment by…

    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 · D2025-08-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 record review and interviews, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for two (#2 and #14) of three residents reviewed for restorative services out of 28 sample residents.Specifically, the facility failed to:-Ensure Resident #2 and Resident #14 were offered and provided with a restorative nursing program to maintain and/or prevent deterioration of their current levels of function and mobility; and,-Ensure Resident #14 was provided with a splint, palm guard or a rolled wash cloth in his left hand to prevent potential worsening of his hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).Findings include: I. Facility policy and procedure The Area of Focus: Restorative Nursing policy and procedure, revised 1/3/25, was received by the nursing home administrator (NHA) on 8/15/25 at…

    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 · D2025-08-13 · 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

    Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one residents (#10) out of 28 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Resident #10. Findings include:I. Professional referenceAccording to the Lantus (insulin Glargine) How to use your pen retrieved on 8/18/25 from https://www.lantus.com/dam/jcr:2cfa1d37-1b5d-445d-83cd-8eaaeaeef48b/lantus-quick-reference-patient-brochure.pdf It revealed in pertinent part, Step 3 perform a safety test. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that the insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times if there is still no insulin coming out, use a new needle and do the safety…

    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 · E2024-12-04 · tag F0660 — pattern
    Plan the resident's discharge to meet the resident's goals and 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 interviews and record reviews, the facility failed to ensure an effective discharge planning process for three (#8, #6 and #7) out of four residents reviewed out of 14 sample residents. Specifically, the facility failed to: -Ensure the discharge planning process was documented in Resident #8, Resident #6 and Resident #7's medical record; and, -Ensure the interdisciplinary team was involved in the discharge planning process for Resident #8, Resident #6 and Resident #7. Findings include: I. Resident #8 A. Resident status Resident #8, age [AGE], was admitted on [DATE] and discharged home on 9/4/24. According to the September 2024 CPO diagnoses included retention of urine, hypertension, type 2 diabetes without complications and muscle weakness. The 6/3/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. The resident required supervision or touch assistance with activities of daily living. The MDS assessment indicated the 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-04 · tag F0676 — failed to keep up residents' daily-living abilities — pattern
    Ensure 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 care and services for an activity of daily living (ADL) for four (#13, #5, #9 and #14) out of five residents reviewed out of 14 sample residents. Specifically, the facility failed to ensure meal assistance was provided for Resident #5, Resident #9, Resident #13 and Resident #14, who required physical assistance and encouragement with food intake. Findings include: I. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE] and re-admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses include [NAME] Syndrome (absence of one X chromosome in females, symptoms include certain learning disabilities), dementia, mixed incontinence and gastro-esophageal reflux disease (GERD) with esophagitis, with bleeding. The 10/17/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight…

    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 · D2024-12-04 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 the discharge summary was complete for two (#7 and #8) of three residents reviewed for discharge out of 14 sampled residents. Specifically, the facility failed to ensure completed discharge summaries were completed and included a recapitulation of the resident's stay for Resident #7 and Resident #8. Findings include: I. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE] and discharged home on 8/21/24 According to the August 2024 computerized physician orders (CPO), diagnoses included bilateral hip osteoarthritis and bilateral total hip replacement. Based on a health status note on 8/8/24 and a skilled nursing progress note from 8/19/24, Resident#7 was aware of surroundings and able to make needs known. B. Record review The Discharge summary, dated [DATE], documented the resident was discharged home. The discharge summary failed to show that all areas on the form were completed. The following were missing: -Physical…

    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
Show the remaining 15 citations
  • Potential for harm · D2024-12-04 · 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 record review and interviews, the facility failed to manage pain in the manner consistent with professional standards of practice for one (#11) of four residents reviewed for pain out of 14 sample residents. Specifically, the facility failed to ensure Resident #11's pain was managed appropriately and consistently to meet the resident's stated level of acceptable pain. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, reviewed 9/5/24, was received from the nursing home administrator (NHA) on 12/4/24 at 1:01 p.m., read in pertinent part, Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. A resident will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition. An individualized pain management care plan will…

    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 · D2024-12-04 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 residents requiring treatments and services for mental disorders or psychosocial adjustment difficulties received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well being for two (#2 and #4) of four residents reviewed out of 14 sample residents. Specifically, the facility failed to provide mental health counseling services for Resident #2 and Resident #4. Findings include: I. Facility policy and procedure The Behavioral Health Services policy, reviewed on 9/6/24, was received from the nursing home administrator (NHA) on 12/4/24 at 1:02 p.m. The policy read in pertinent part, The facility will provide behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meets each resident's needs and includes individualized approaches to care. The nursing assessment and social services assessment 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure stored kitchen equipment were clean and sanitary; and, -Ensure systems were in place to prevent compromised food safety through proper staff training. Findings include: I. Failure to ensure stored kitchen equipment were clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Non food-contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-28 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 views, grievances and recommendations were considered for resident council members. Specifically, the facility failed to: -Effectively address, resolve and demonstrate the facility's response to grievances brought up in resident council; and, -Ensure resident council meetings were meeting the views and agendia desired by the resident council members. Findings include: I. Facility policy and procedure The Resident Council policy, revised 10/6/22, was provided by the nursing home administrator (NHA) on 9/26/23. It read it pertinent part, A resident group is defined as a group of residents that meet regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life. The activities director or social services will facilitate follow up on all complaints, suggestions and ideas presented at the council meeting and will report results at the next meeting for the residents' information. This information will be included in the minutes. The activities…

    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 · E2023-09-28 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews for four of five certified nurse aides (CNAs) reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular inservice education based on the outcome of the reviews for CNA #1, #2, #3 and #4. Findings include: I. Record review CNA #1 (hired 9/27/22), CNA #2 (hired 1/31/22), CNA #3 (hired 9/18/2020) and CNA #4 (hired 12/26/2000) did not have an annual performance review completed. The CNAs did not have an inservice education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 9/27/23 at 10:40 a.m. She said the facility had not completed any annual performance reviews. She said the facility would develop a plan to complete the performance reviews going forward.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-28 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations. Specifically, the facility failed to develop a facility assessment which included staff education and staff competencies. Findings include: I. Facility assessment The facility assessment, provided by the nursing home administrator (NHA) on 9/25/23 at 12:40 p.m. had been updated on 2/13/23 and reviewed by the quality assurance performance improvement committee on 2/14/23. The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population. The facility census and conditions provided on 9/25/23 identified the following:…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-28 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for four (#4, #24, #16 and #12) of six residents reviewed for vaccinations out of 18 sample residents. Specifically, the facility failed to ensure Residents #4, #24, #16 and #12 were offered and/or received pneumococcal immunization. Findings include: I. Professional reference According to Center for Disease Control and Prevention, reviewed 11/21/22, retrieved on 2/14/23 from https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged 65 years (or older), the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. In the majority of seasons, influenza vaccines will become…

    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 · Dcited before2023-09-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 interviews and record review, the facility failed to ensure one (#17) out of 18 sample residents were kept free from sexual abuse. Specifically, the facility failed to prevent sexual abuse to Resident #17 from Resident #16. Findings include: I. Facility policy and procedure The Abuse Policy, reviewed 7/18/23, provided by the nursing home administrator (NHA) on 9/25/23 at 12:40 p.m., included in part: It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Procedure: Establishing a safe environment that supports, to the extent possible, a resident's consentual sexual relationship and by establishing policies and protocols for preventing sexual abuse. II. Witnessed incident on 8/12/23 A. Resident #16 progress note On 8/12/23 at 5:05 a.m. the progress note documented, Resident found in roommates bed touching roommate inappropriately. Taken back to his own bed. B. Resident #17 progress note On 8/12/23 at 11:41p.m. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for two (#4 and #11) of 12 residents reviewed for activities of daily living (ADL) of 18 sample residents. Specifically, the facility failed revised the ADL care plan to include person-centered, resident-specific refusal of bathing/showers for Residdent #4 amd Resident #11. Findings include: I. Resident #4 A. Resident status Resident #4, age under 65 years, was admitted on [DATE]. According to the September 2023 CPO, the diagnoses included paranoid schizophrenia, and chronic fatigue. The 9/1/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The resident did not have behaviors of rejecting evaluations or care. The resident was independent in his ADLs, only requiring set up and supervision with bathing. B.…

    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 · D2023-09-28 · tag F0947 — failed to train nurse aides adequately — isolated
    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 — the official record, unedited, may be distressing

    Based on record review and interviews, the facility failed to ensure 12 hour in-service training for certified nurse aides (CNAs). Specifically, the facility failed to ensure CNAs received 12 hours annually training for two of five CNAs. Findings include: I. Training review Five CNAs were reviewed for the annual required 12 hours training. Training records revealed CNA #2 (hired 1/31/22) and CNA #3 (hired 9/18/2020) of the five CNAs reviewed did not have the required 12 hour annual training. II. Interview The director of nursing (DON) was interviewed on 9/27/23 at 10:40 a.m. She said she was not aware there were CNAs that did not have the 12 hours required annual training. She said the required 12 annual training included continuing education and changes. She said systems would be improved to ensure CNA training was completed as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-09-11 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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

    Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on the hand held shower appliance in one of one shower and one outside garden hose, increasing the risk of contaminating the facility's main water supply. Findings include: I. Professional references According to the Environmental Protection Agency's Cross-Connection Control, 11/20/15, http://water.epa.gov/infrastructure/drinkingwater/pws/crossconnectioncontrol/ (April 2017) in pertinent part: -Cross-connections (areas where potable and non-potable water can mix) create a potential hazard because of the potential contamination of drinking water. -Potential areas for cross-connections include washroom facilities. -The purpose of using a backflow device is to prevent the addition of contaminated fluids and gases into the potable water supply system through a cross connection. According to the Department of Health and Human…

    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 · D2019-09-11 · 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 one (#25) of one resident reviewed of 26 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to identify, assess, coordinate care, and care plan the use of a transcutaneous electrical nerve stimulation (TENS) unit. Findings include: I. Manufacturer's information According to the manufacturer's instructions for Medtronic (2017), Verify Evaluation system for Sacral Neuromodulation, About your External Neurotransmitter, Stimulation sensation during the evaluation period. The amount of stimulation is under your control. Stimulation should never be uncomfortable . If you are not receiving symptom relief, consider adjusting stimulation as follows: a. Decrease stimulation to 0.0. B. increase stimulation back to the previous or desired level. II. Facility policy and procedure 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 observations, record review and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible in one of two resident hallways. Specifically, the facility failed to ensure: -Oxygen concentrators were plugged into a wall outlet instead of a non-medical grade power strip that came with the device; and -Ground circuit fault interrupter (GCFI) outlets were installed in residents' rooms. Findings include: I. Oxygen concentrator plugged into power strip A. Initial observations Observations of the resident living environment conducted on 9/9/19 at 10:10 a.m. revealed in rooms #209 and #204, the oxygen concentrators were plugged into power strips. B. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 9/11/19 at 10:59 a.m. The above observation was reviewed. The MS documented the concern and said no medical equipment should be plugged into a power strip. The MS said if the power strip was…

    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 · D2019-09-11 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 nursing staff was able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (#25) of 26 sampled residents. Specifically, the facility failed to train nursing staff on the use of resident #25's transcutaneous electrical nerve stimulation (TENS) unit. Cross-reference F684 - failure to identify, assess, coordinate care, and care plan the use of a TENS unit. Findings include: I. Resident status Resident #25, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2019 computerized physician order (CPO), diagnoses included overactive bladder, personal history of urinary tract infections (UTI), neuromuscular dysfunction of bladder, and infection and inflammatory reaction due to other urinary catheter. The 7/26/19 MDS assessment revealed, the resident had no cognitive impairment with a…

    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 · D2019-09-11 · 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 and interviews, the facility failed to ensure all drugs and biologicals were properly labeled to ensure safe administration in one of two medication carts and one of one medication storage room refrigerators. Specifically, the facility failed to: -Ensure a Humalog insulin vial was dated when first opened; -Ensure a Lantus pen was dated when first opened and used; and -Ensure an Aplisol Tuberculin multi-dose solution vial was dated when first opened and used. Findings include: I. Manufacturers' instructions According to Humalog insulin lispro injections instructions (2018), retrieved from https://www.humalog.com/type-2-diabetes/?gclsrc=aw.ds&gclid=EAIaIQobChMI6cKxv8zV5AIVlB-tBh2n7AvjEAAYASAAEgKBjvD_BwE&gclsrc=aw.ds : Throw away all opened vials after 28 days of use even if there is insulin left in the vial. Unopened vials should be thrown away after 28 days, if they are stored at room temperature. Unopened vials can be used until the expiration date on the carton and label if they have been stored in the refrigerator. According to Lantus prescribing information…

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE CENTERS OF AMERICA — 194 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 2 of 53.4-1.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV 2 of 5Life Care Center Of TullahomaTullahoma, TN

Showing 40 of 193; 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
DEVELOPERS INVESTMENT COMPANY INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2006
IRENE, JILLIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/03/2023
LOVELESS, DAWNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/02/2025
SCHMIDT, DEREKIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 10/18/2012
CROSS, CINDYIndividualCORPORATE OFFICERsince 05/07/1996
HENRY, TERRYIndividualCORPORATE OFFICERsince 08/16/1999
LAY, LISAIndividualCORPORATE OFFICERsince 02/09/2018
PRESTON, FORRESTIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/06/1976
SWANKER, RICHARDIndividualCORPORATE OFFICERsince 01/01/2022
THURMOND, JOANIndividualCORPORATE OFFICERsince 09/22/2000
COLORADO MEDICAL INVESTORS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/1996
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
MCCURRY, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024

CMS files one row per role, so the 24 rows in the source record cover these 16 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.

3 organizational owners 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.

$3.8M
Net patient revenuemost recent cost report
-14.0%
Operating marginrevenue minus expenses
$777K
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 9%Other / private 23%

This home reported $777K paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$384per resident / day
operating cost
$11,664per month
≈ monthly operating cost
$337per 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

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.

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 065217. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-13, 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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