Brookdale Skyline
2365 Patriot Hts, Colorado Springs, CO 80904 · For profit - Corporation · 82 certified beds · (719) 667-5360 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2022
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,110 in federal fines (most recent 2025-12-10)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 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 fell from 4 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 4.7% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.9% | 8.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.8% | 3.4% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.8% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.2% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.5% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.2% | 20.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 90.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.1% | 20.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.1% | 12.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.91 | 1.38 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.81 | 1.74 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.0% 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 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.4% 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 57 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.0%CMS range 59.9–74.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.9%CMS range 6.4–13.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 74.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 75.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.0%CMS range 3.3–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 82 beds and averages 44.9 residents a day — about 55% occupied, or roughly 37 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 4.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.48 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 is at or above 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 3.64 hrs/resident/day on weekends vs 4.92 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 1.65 to 1.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · Gcited before2025-12-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#2) of five residents reviewed for accidents out of seven sample residents. The facility failed to ensure staff transferred Resident #2 appropriately with a mechanical lift which resulted in a fall with major injury for the resident.Resident #2 was admitted to the facility for rehabilitation services on 10/7/25. The resident's care plan directed staff to utilize a mechanical lift (a sit to stand lift) for transfers. On 10/11/25 certified nurse aide (CNA) #1 and CNA #2 used a gait belt (a belt that fastens around the waist, used for someone with mobility issues) to transfer Resident #2 from the toilet to her wheelchair. Resident #2 stood, and then lost the ability to bear weight in one of her legs and fell to the floor.Immediately after the incident, Resident #2 complained of right knee pain. The pain worsened and the resident was transported to the hospital on [DATE] where…
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.
- Actual harm · G2022-06-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to take the necessary steps to ensure one (#8) of one resident was free from abuse out of 16 sample residents. Resident #8 was admitted to the facility for long term care on 12/18/19 with diagnoses of vascular dementia without behavioral disturbance, hemiplegia (paralysis) and hemiparesis (partial paralysis, weakness) following nontraumatic intracerebral hemorrhage (stroke) affecting left non-dominant side, and pain. The resident was dependent on staff for activities of daily living which included toileting and upper and lower body dressing. The resident had both physical and verbal behavior symptoms directed towards others and had rejections related to care. The facility failed to address the behaviors to ensure resident safety (cross-reference F744 for dementia care). Due to the facility not addressing the verbal and physical behaviors, Resident #8 was involved in an incident involving abuse from a certified nurse aide (CNA). Due to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-11 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 three (#6, #8 and #9) of seven residents reviewed for ADLs out of 13 sample residents. Specifically, the facility failed to: -Ensure staff used a gait belt when transferring Resident #6 from a recliner to the wheelchair while taking the resident to his room to provide incontinence care; -Ensure staff properly used a Hoyer lift (mechanical lift) when transferring Resident #8 to her bed to provide incontinence care; and, -Ensure Resident #8 and Resident #9 were provided with timely incontinence care. Findings include: I. Professional reference According to the Joerns Hoyer manufacturer guidelines, 2021, retrieved on 6/16/25, from https://www.https://www.joerns.com/product/hoyer-pro-slings/, A sling is an item of moving and handling equipment that is used with a mechanical lift in order to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-17 · tag F0730 — widespreadObserve 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 interviews, the facility failed to complete a performance review of every nurse aide at least once every 12-months and provide regular in-service education based on the outcome of these reviews for two of two certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of the reviews for CNA #2 and CNA #3. Findings include: I. Facility policy and procedure The Annual Performance Planning Guide, undated, was provided by the nursing home administrator (NHA) on 4/17/25 at 4:47 p.m. It read in pertinent part, Performance planning is a critical part of the performance management process. While annual reviews are a look back, performance plans are a look forward. A collaborative process between associate and supervisor, they set the foundation for performance management by establishing clear and defined individual performance and development goals for the year. Revisit the performance plan throughout the year to measure progress, discuss obstacles, give…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure an infection prevention and control programs (IPCP) was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of three units. Specifically, the facility failed to ensure staff wore the appropriate PPE when providing wound care for Resident #50 who was on enhanced barrier precautions (EBP) related to an abdominal wound. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, retrieved on 4/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care was provided such care, consistent with professional standards of practice for one (#1) of two residents reviewed for the use of supplemental oxygen of 27 sample residents. Specifically, the facility failed to ensure Resident #1's oxygen was consistently administered according to physician's orders. Findings include: I. Facility policy and procedure The Oxygen Administration policy, revised April 2024, was provided by the nursing home administrator (NHA) on 4/17/2025 at 3:03 p.m. It read in pertinent part, The nurse should monitor oxygen administration and record the resident's response to oxygen therapy in the medical record. Verify that there is a physician's order for the procedure. Review the healthcare provider's orders or community protocol for oxygen administration. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the April 2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychosocial well-being for two (#29 and 42) of three residents reviewed for dementia care out of 27 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #29 and Resident #42 to provide the resident with their highest practicable quality of life and care. Findings include: I. Facility policy and procedure The Dementia Care policy and procedure, revised February 2022, was received from the nursing home administrator (NHA) on 4/16/25 at 10:39 a.m It read in pertinent part, Residents who have been diagnosed as having dementia should have a resident-centered care plan to maximize remaining abilities and quality of life. II. Resident #29 A. Resident status Resident #29, age [AGE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 meals were served according to the resident's preferences for one (#103) of three residents out of 27 sample residents. Specifically, the facility failed to ensure Resident #103 received the meal items she ordered. Findings include: I. Resident #103 A. Resident status Resident #103, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included dementia, depression and Parkinson's disease (a disease that causes tremors). B. Resident interview and observations Resident #103 was interviewed on 4/17/25 at 12:20 p.m. The resident said she had problems with her lunch meal. The resident's meal ticket did not indicate the resident's choice for the lunch meal on 4/17/25 as it was blank. Resident #103 said this happened all the time since she was admitted to the facility. The resident said her son helped her fill out her meal tickets but the meal ticket that was delivered with her lunch tray was blank. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-31 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
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 observation, record review, and interviews, the facility failed to protect the residents' privacy by using video monitoring for eight (#15, #27, #36, #37, #41, #43, #80 and #203) of eight residents reviewed out of 30 sample residents. Specifically, the facility failed to obtain resident and/or family consent for resident video monitoring, failed to consistently observe the video displays for resident behaviors, failed to protect the video display from others not involved in direct resident care, failed to post signage that indicated video cameras were in use and failed to obtain consent from roommates when cameras were in use. Findings include: I. Facility policy The Electronic Monitoring policy, dated October 2019, was requested and received on 8/30/23 from the nursing home administrator (NHA). The policy included in pertinent part: The facility allows residents and/or their legal representative to monitor their room through the use of electronic monitoring devices subject to the procedures listed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-31 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails); and -Ensure surface disinfectant times were followed. Findings include: I. Professional references A. Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review, The Journal of Hospital Infection, 2021 Jul;113:104-114 retrieved on 9/5/23 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0574 — isolatedThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents. Findings include: I. Resident group interview The group interview was conducted on 8/30/23 at 10:35 a.m. with five residents (#4, #5, #13 and #45) identified by assessment and the facility as interviewable. All four residents said they did not know they could file a complaint with the State Agency and they did not know where the facility posted information in regard to pertinent State Agencies' contact information and it was not reviewed in the resident council meeting. II. Observations and staff interviews On 8/28/23 at 10:46 a.m. observation of the mandatory posting for the State Agency was made on the fourth floor prior to entering the unit. An eight inch by 11 inch paper was stapled to 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.
- Potential for harm · D2023-08-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 two (#16 and #34) of four out of 30 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: -Ensure Resident #16 was wearing her geri gloves (to help her skin from bruising and skin tears) at all times when out of bed; and, -Ensure Resident #34 was wearing her prevalon boots (which help reduce the risk of pressure injuries to the heel/foot). Findings include: I. Resident #16 A. Resident status Resident #16, age above 80, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included rheumatoid arthritis, protein-calorie malnutrition, and unspecified dementia. The 6/3/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2023-08-31 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 observation, record review, and interviews, the facility failed to provide care and treatment for the resident's hearing aid that was required to maintain hearing ability for one (#21) of one resident out of 30 sample residents. Specifically, the facility failed to develop a resident centered care plan for the care and treatment to maintain ability to hear, failed to ensure the resident's hearing aid was maintained in working condition, failed to identify communication needs and preferences for the resident with hearing impairment when the device did not work, and failed to ensure hearing impairment was included as a current diagnosis for treatment. Findings include: I. Facility policy The Care of Hearing Impaired Resident policy, dated October 2016, was requested and received on 8/30/23 from the nursing home administrator (NHA). The policy documented in pertinent part: Associates will receive guidelines for providing care to a resident with a hearing impairment. Policy detail -Review the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one (#7) of three residents who required respiratory care received the care consistent with professional standards of practice, out of 30 sample residents. Specifically, for Resident #7 the facility failed to: -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #7's CPAP; -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of the CPAP; -Ensure a physician's order was in place for oxygen therapy for Resident #7; and -Ensure a care plan was in place to include oxygen route, frequency, and liters required. Findings include: I. CPAP A. Facility policies and procedures The CPAP/BiPAP policy, last revised September 2017,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
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 maintain emergency response carts and equipment in safe operating condition for two of three emergency carts. Specifically, the facility failed to ensure emergency oxygen canisters on the emergency response carts were maintained and ready for use. Findings include: I. Facility policy The Emergency Cart and Checklist policy, dated July 2015, for maintaining patient care equipment was provided by the nursing home administrator (NHA) on 8/30/23 and documented in pertinent part: The emergency medical cart is readily accessible in the event of an emergency. -The emergency cart will be checked daily by the nursing associates; -Equipment will be be checked to verify proper functioning and availability; -The emergency cart will also be checked and restocked accordingly after every use. II. Observations and interviews On 7/26/23 at 3:15 p.m. the fifth floor emergency response cart was observed with licensed practical nurse (LPN) #1. Observations revealed the oxygen canister designated for the emergency response cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision was provided to prevent accidents, for two (#14 and #34) for elopement out of 16 sample residents. Specifically the facility: -Failed to complete an elopement assessment at the time of wander guard placement for Resident #14 and #34, and, -Failed to attempt an alternate intervention prior to the implementation of a wander guard for Resident #14. I. Facility policy The Elopement Risk policy, revised October 2020, provided by the nursing home administrator (NHA) on 6/21/22 at 3:16 p.m., included: Skilled nursing elopement: Any incident where a resident leaves the interior of the skilled nursing portion of the community; unescorted or unsupervised, with or without injury, when it has previously been determined that he/she needs supervision. Interventions may include, but are not limited to: -Frequent monitor (Q 15 minute checks)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-22 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one (#8) of three residents reviewed for dementia care of 16 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to address Resident #8's behaviors that were directed towards staff and the resident was involved in an altercation with a caregiver. Findings include: I. Facility policy The Dementia Care policy and procedure, revised November 2019, was provided by the nursing home administrator (NHA) on 6/22/22 at 11:34 a.m. It read, in pertinent part: Skilled Nursing residents who have been diagnosed as having dementia and those with otherwise impaired cognition should have a resident-centered care plan to maximize remaining abilities and quality of life. When a resident exhibits behavioral expressions, associates should attempt to discover possible contributing factors. Tools such as the Survey of Discomfort in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$9,110 in federal fines across 1 penalty.
- $9,110 — penalty dated 2025-12-10
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 BROOKDALE SENIOR LIVING — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.5 | +1.5 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 5 of 5 | 4.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 11 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BLC MANAGEMENT - 3, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 03/30/2005 |
| BROOKDALE F&B, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 03/30/2025 |
| BROOKDALE LIVING COMMUNITIES, INC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/30/2005 |
| BROOKDALE SENIOR LIVING INC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/28/2008 |
| KUSSOW, DAWN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 04/30/2025 |
| WHITE, CHADWICK | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 03/09/2018 |
| PRUDENTIAL MULTIFAMILY MORTGAGE LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | since 12/20/2016 |
| SMITH, THOMAS | Individual | CORPORATE DIRECTOR | since 04/30/2007 |
| LA MARRE, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/22/2017 |
| MUHLBAUER, ANNELIESE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/22/2025 |
| MUNOZ, ANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/05/2024 |
| REDDY, VIKAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/22/2025 |
| STENGLE, NIKOLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/08/2025 |
| WHITLEY, MATTHEW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/12/2025 |
| BKD FM7 HOLDCO MI-CO LLC | Organization | ADP OF THE SNF | since 12/20/2016 |
| BKD SKYLINE PROCO LLC | Organization | ADP OF THE SNF | since 12/20/2016 |
| LBMC PC | Organization | ADP OF THE SNF | since 01/01/2024 |
| PRUDENTIAL FINANCIAL | Organization | ADP OF THE SNF | since 09/24/2025 |
| WALTERS FINANCIAL SERVICES INC | Organization | ADP OF THE SNF | since 07/22/2025 |
| ASHER, JORDAN | Individual | ADP OF THE SNF | since 02/24/2020 |
| DRAYTON, CLAUDIA | Individual | ADP OF THE SNF | since 06/18/2024 |
| FIORAVANTI, MARK | Individual | ADP OF THE SNF | since 04/13/2025 |
| FREED, VICTORIA | Individual | ADP OF THE SNF | since 10/29/2019 |
| HAUSMAN, JOSHUA | Individual | ADP OF THE SNF | since 04/24/2025 |
| MACE, ELIZABETH | Individual | ADP OF THE SNF | since 06/18/2024 |
| WARREN, DENISE | Individual | ADP OF THE SNF | since 10/04/2018 |
| WIELANSKY, LEE | Individual | ADP OF THE SNF | since 04/23/2015 |
CMS files one row per role, so the 37 rows in the source record cover these 27 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.
10 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.
This home reported $1.7M 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
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
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.
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 065382. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.