Sundance Skilled Nursing And Rehabilitation
2612 W Cucharras St, Colorado Springs, CO 80904 · For profit - Limited Liability company · 68 certified beds · (719) 632-7474 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- it has a citation for mishandling residents’ money or property (F0565)
- 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,901 in federal fines (most recent 2025-08-15)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 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.
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 | 4.6% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.1% | 4.7% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 8.8% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.8% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.1% | 13.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.6% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.2% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.0% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.7% | 20.0% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.17 | 1.38 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.48 | 1.74 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
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 99% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not 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 worsened | not 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 hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 68 beds and averages 60.0 residents a day — about 88% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.64 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 2.68 hrs/resident/day on weekends vs 3.28 on weekdays — 18% thinner on weekends. RN hours go from 1.08 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-08-15 · 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 one (#1) of three residents reviewed for accidents received adequate supervision out of 14 sample residents.Specifically, the facility failed to ensure Resident #1 was not able to access hazardous chemicals.Resident #1, who was admitted to the facility on [DATE], had a history of dementia and of wandering within the facility. On [DATE] at 1:40 p.m., Resident #1 was able to obtain a bottle of a cleaning chemical that was located in a residential hallway on a maintenance cart that was unsecured and unsupervised.Resident #1 was found by certified nurse aide (CNA) #1 holding the bottle containing a cleaning chemical. Resident #1 was observed to have a blue substance on his lips, which was determined by the facility to be consistent with the contents of the bottle.Resident #1 was reported to have mouth and stomach pain after the incident. He was evaluated by a physician at the facility immediately following the incident and transferred…
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 · E2026-02-26 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure that clean linens were provided to residents on a daily basis. Specifically, the facility failed to ensure clean hand towels and washcloths were provided to residents.Findings include:I. ObservationsObservations made throughout the survey (from 2/23/26 to 2/26/26) revealed there were no towel racks inside the residents' bathrooms. On 2/23/26 at 3:38 p.m. room [ROOM NUMBER] B had no hand towels or washcloths.On 2/23/26 at 5:43 p.m. room [ROOM NUMBER] A and B had no hand towels or washclothsOn 2/25/26 beginning at 2:27 p.m., the following observations were made:-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room [ROOM NUMBER] had no hand towels or washcloths;-room…
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 before2026-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 environment were free of accidents and hazards for one (#11) of two residents reviewed for accidents out of 41 sample residents and three of three emergency crash carts. Specifically, the facility failed to:-Ensure Resident #11 was assessed to determine if he was safe to smoke independently after an incident of unsafe smoking; and,-Ensure medical grade power strips were readily available in the crash carts (a specialized, mobile, and organized unit of trays and drawers on wheels containing essential life-saving equipment and medications). Findings include: I. Failed to ensure Resident #11 was assessed to determine if he was safe to smoke independently after an incident of unsafe smoking A. Facility policy and procedure The Resident Smoking policy and procedure, revised 6/12/25, was provided by the nursing home administrator (NHA) on 2/26/26 at 4:53 p.m. It read in pertinent part, Smoking is not allowed inside 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 · Ecited before2026-02-26 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 stored, secured, and labeled in accordance with accepted professional standards in two of two medication carts.Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy, dated February 2023, was provided by the nursing home administrator (NHA) on 1/26/26 at 9:23 p.m. It read in pertinent part, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date, when applicable; resident's name; route of administration; and, appropriate instructions and precautions.II. ObservationsOn 2/26/26 at 8:48 a.m. the second floor medication cart 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.
- Potential for harm · E2026-02-26 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and temperature.Findings include: I. Facility policy and procedure The Resident Food Preferences policy, dated July 2017, was provided by the nursing home administrator (NHA) on 2/26/26 at 9:23 p.m. It read in pertinent part, The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's quality assessment and performance improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. II. Resident group interview A group of five residents (#2, #7, #24, #56 and #58) who were assessed by the facility to be interviewable, were interviewed together on 2/25/26 at 10:30 a.m. Resident #7 said the vegetables were often overcooked and she did not believe the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-26 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake 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 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 necessary maintenance repairs were communicated and completed in a timely manner in the kitchen area.Findings include:I. ObservationsDuring a walkthrough of the kitchen on 2/25/26 from 11:28 a.m. to 11:53 a.m., the following was observed: -The wall behind the toaster was observed with visible burned marks. The wallpaper was observed peeling in multiple areas. There were sections of wallpaper observed missing above the toaster near the ceiling. -There were six holes observed in the wall to the right of the spice rack on the same wall as the toaster.-There were multiple areas of chipped paint observed on the ceiling along two pipes adjacent to the wall where the toaster was located. -There were multiple chipped paint marks observed on the ceiling along one pipe which was adjacent to the pipe line next to the wall where the toaster was located. -There were approximately twenty 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 · D2026-02-26 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 (#69) of two residents reviewed for personal property out of 41 sample residents was able to retain their personal belongings. Specifically, the facility failed to receive consent from Resident #69 or his responsible party before disposing of his personal belongings after the resident was discharged to the hospital.Findings include:I. Resident #69A. Resident statusResident #69, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included quadriplegia and systemic lupus. The [DATE] minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Record reviewA nursing note, dated [DATE], revealed Resident #69's physician assessed him and found that the resident had phimosis (a condition where the foreskin could not be retracted) which required medical intervention. The physician ordered…
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 before2026-02-26 · tag F0565 — failed to support the resident council — isolatedHonor 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 consider resident and family group views and act upon grievances and recommendations.Specifically, the facility failed to provide the residents the opportunity to share views, grievances, and recommendations to dietary related issues in the resident council meetings.Findings include:I. Facility policy and procedureThe Grievance policy, undated, was provided by the nursing home administrator (NHA) on 2/26/26 at 4:53 p.m. It read in pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups will be considered. Actions on such items will be responded to in writing, including a rationale for the response.II. Resident group interviewFive alert and oriented residents (#24, #2, #7, #56 and #58) who regularly attended the resident council meetings and were deemed interviewable by assessment and the facility were interviewed together on 2/25/26 at 10:30 a.m. The residents were identified as alert and oriented through facility and assessment.The group of residents said the facility did…
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 · D2026-02-26 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide ongoing programs to support choices of activities and engaging programming based on the comprehensive assessment and care plan that were designed to meet the interests of and support the physical, mental, and psychosocial well-being of two (#46 and #55) of three residents reviewed for activities out of 41 sample residents.Specifically, the facility failed to offer and provide personalized meaningful activity programs for Resident #46 and Resident #55 as documented in their care plans.Findings include:I. Resident #46A. Resident statusResident #46, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO) diagnoses included unspecified dementia, mood disturbance and anxiety. The resident was in hospice care.The 2/18/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out 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.
- Potential for harm · D2026-02-26 · 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 residents received treatment treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#67) of two residents reviewed out of 41 sample residents.Specifically, the facility failed to:-Ensure physician's orders were obtained for Resident #67's insulin pump and that the insulin pump was being appropriately monitored; -Ensure Resident #67's blood glucose (sugar) levels were being monitored; and,-Ensure Resident #67 received a carbohydrate-controlled diet, per her request.Findings include:I. Professional referenceAccording to the American Diabetes Association's Check Your Blood Glucose - Diabetes Testing And Monitoring retrieved on 3/4/26 from https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar, The logging of your blood glucose results is vital. When you bring your log to your health care provider, you will have a good picture 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.
- Potential for harm · Dcited before2026-02-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent of additional pressure injuries for one (#46) of two residents out of 41 sample residents. Specifically, the facility failed to:-Ensure Resident #46, who had pressure injuries, was repositioned and provided incontinence care in a timely manner; and,-Ensure staff consistently implemented care planned pressure injury prevention interventions for Resident #46.Findings include:I. Professional referenceAccording to Basic Nursing third edition; [NAME] S. Treas, [NAME], [NAME] H. [NAME] (2022), page 1214-1215, Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort. People who are immobile are more prone to pressure injury as a result of reduced…
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 16 citations
- Potential for harm · D2026-02-26 · 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 received necessary respiratory care and services per professional standards of practice for two (#24 and #67) of three residents reviewed for respiratory care out of 41 sample residents.Specifically, the facility failed to:-Ensure the physician's order matched the resident's preference for oxygen administration for Resident #24; and,-Ensure there was a physician's order for oxygen use for Resident #67.Findings include: I. Facility policy and procedure The Oxygen Administration policy, dated October 2010, was provided by the nursing home administrator (NHA) on 2/26/26 at 9:23 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of 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.
- Potential for harm · D2026-02-26 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#37) of two residents out of 41 sample residents. Specifically, the facility failed to: -Ensure a complete and thorough pain assessment was completed that identified Resident #37's history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident's quality of life; -Identify Resident #37's goals for pain management and acceptable level of pain; -Identify Resident #37's locations of pain; and, -Ensure Resident #37's location of pain was consistently identified when administering pain medication to the resident.Findings include: I. Facility policy and procedureThe Pain Management policy, revised June 2022, was provided by the nursing home administrator (NHA) on 2/26/26 at 6:46 p.m. It read in pertinent part, The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#30) of three residents reviewed for ancillary services out of 41 sample residents received dental services timely. Specifically, the facility failed to: -Ensure Resident #30 was provided timely emergency dental services after reporting tooth pain; and, -Ensure Resident #30 was offered routine dental care.Findings include: I. Facility policy and procedure The Dental Services policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 2/26/26 at 6:46 p.m. It read in pertinent part, Routine and 24-hour emergency dental services are provided to the residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, referral to community dentist or referral to other health care organizations that provide dental services. Selected dentists must be available to provide follow up care. Failure of a dentist to provide…
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 · D2026-02-26 · 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 (#37) of five residents out of 41 sample residents. Specifically, the facility failed to offer food choices according to Resident #37's preferences.Findings include: I. Facility policy and procedure The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/26/26 at 9:23 p.m. It read in pertinent part, Staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. The food services department will offer a variety of foods at each scheduled meal. II. Resident #37A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic pain syndrome,…
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 before2026-02-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically, the facility failed to ensure suction equipment was maintained in a sanitary manner.Findings include:I. Professional referenceAccording to the Healthcare Sterile Processing Association, August 2023, retrieved on 3/4/26 from https://myhspa.org/wp-content/uploads/2023/08/Fundamentals-of-sterile-storage.pdf, Healthcare facilities must take action to create an environment that properly protects sterile packages. This includes securing a proper sterile storage environment and developing policies and procedures to help ensure sterile packages are safely stored and handled. If items are not properly protected or something unexpectedly happens, stored items may become contaminated. Providing the appropriate sterile storage environment and training personnel about proper handling and other essential sterile storage…
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 · D2026-02-26 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to have an adequately equipped call system to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff area. Specifically, the facility failed to ensure all parts of the call light system were functioning properly in the common bathroom near the main dining room and the day room on the first floor.Findings include:I. Resident interviewResident #38 was interviewed on 2/23/26 at 1:00 p.m. Resident #38 said he was newly admitted to the facility and had gone to the bathroom in the common bathroom in the basement, near the dining room. He said he pulled the cord to call staff for help. He said the help never came as he waited for more than 20 minutes. Resident #38 said he used his cell phone and called a family member to ask for the facility to be called to come and help him. II. Observations and staff interviewOn 2/23/26 at 5:14 p.m. the bathroom call light was turned on in the common resident bathroom in the basement , next to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0923 — isolatedHave enough outside ventilation via a window or mechanical ventilation, or both.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to have adequate outside ventilation by means of a window or mechanical ventilation or a combination of the two for two out of three common bathrooms and two resident bathrooms, affecting eight residents.Specifically the facility failed to ensure the ventilation fans were clean and in good repair.Findings include:I. ObservationsOn 2/23/26 at 10:00 a.m. the 2nd floor was odorous.On 2/23/26 at 2:30 p.m. the shared bathroom in room [ROOM NUMBER] and room [ROOM NUMBER] had strong odors of a combination of urine and feces. There were no windows in the bathroom and the ventilation fan could not be heard. The ventilation fan cover had dust built up on it. The bathroom was shared by four residents.On 2/24/26 at 12:48 p.m. the shared bathroom in room [ROOM NUMBER] had strong odors of a combination of urine and feces. The ventilation fan cover had dust built up on it. The bathroom was shared by four residents.On 2/24/26 at 1:00 p.m. the shared bathroom in room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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. Specifically, the facility failed to: -Ensure resident's medical supplies for catheter irrigation were labeled, dated and stored in a sanitary environment. Findings include: I. Facility policies and procedures The Infection Control policy and procedure, undated, was received by the nursing home administrator (NHA) on 2/22/24 at 11:27 a.m. It read in pertinent part, An infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections. The program is based on accepted national infection prevention control standards. The elements of the infection prevention program includes: coordination/oversight of prevention of infection. Important facets of infection prevention include: -educate staff to ensure…
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 · D2023-10-05 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
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 a copy of medical records were provided timely for one (#17) of three out of 18 sample residents. Specifically, the facility failed to ensure records were provided timely upon request for Resident #17 from a court appointed guardian. Findings include: I. Facility policy and procedure The Access to Personal and Medical Records policy, revised May 2017, was provided by the nursing home administrator (NHA) on 10/5/23 at 5:56 p.m. It revealed, in pertinent part, A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request. II. Failure to provide medical records as requested A. Resident representative interview The court-appointed guardian was interviewed on 10/5/23 at 2:08 p.m. She said she had requested Resident #17's medical records on 9/6/23 via email to the NHA. She said the NHA had forwarded the email to the medical records personnel, however she said she had not heard back from the facility. She said prior to the 9/6/23 email, she had…
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 · D2023-10-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, interviews and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain personal hygiene for one (#11) of five residents out of 18 sample residents. Specifically, the facility failed to provide incontinence care timely for Resident #11. Findings include: I Resident status Resident #11, under age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis ((MS) a disease in which the immune system eats away at the protective covering of nerves), dementia, paraplegia (loss of muscle function in the lower half of the body, including both legs), neuromuscular dysfunction of bladder (overactive bladder muscles squeeze more often than normal and before the bladder is full with urine) and need for assistance with personal care. The 7/7/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive…
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 before2023-10-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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, interviews and record review the facility failed to provide the necessary treatment and services for pressure injuries for one (#8) of three residents out of 18 sample residents. Specifically, the facility failed to implement interventions for Resident #8 who had a pressure injury. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages, the National Pressure Injury Advisory Panel - NPIAP web. (2/4/18) retrieved on 10/9/23 from https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definition: Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized…
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 before2023-10-05 · 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, observations, and interviews, the facility failed to ensure residents were free from accidents and hazards for one (#2) of four residents reviewed for falls of 18 sample residents. Specifically, the facility failed to for Resident #2: -Ensure the resident received adequate supervision to prevent repeated falls; -Implement care plan interventions timely, consistently and effectively to prevent resident falls including ensuring the resident had a fully functional call light within reach; anticipating the resident's care needs for toileting, wanting to transfer to go out to smoke or to lay down to rest; -Ensure the resident consistently had nonslip footwear; and, -Reassess the effectiveness of fall prevention methods following repeated falls where interventions failed to prevent repeated falls. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, dated June 2022, was provided by the nursing home administrator (NHA) on 10/5/23 at 5:19 p.m. It revealed…
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 before2022-11-17 · tag F0565 — failed to support the resident council — patternHonor 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 the residents had a right to to be informed of the results or actions taken regarding concerns during resident council meetings. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to ongoing food concerns. Findings include: I. Resident interviews Resident #3 was interviewed on 11/15/22 at 1:34 p.m. She said she was bed bound and always ate meals in her room. She said the food was usually cold and did not taste good. Resident #47 was interviewed on 11/16/22 at 9:19 a.m. Resident #47 served as the Resident Council president and had been the president for at least six months. He said the food being cold had come up in the resident council several times and the solution was that the heated carts were to be plugged in but that did not happen consistently. He said that the nursing staff were to be the ones responsible for plugging them in. Resident #1 was interviewed on 11/16/22 at 10:30 a.m. She said she always ate in her room and the food was always cold. She said…
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 before2022-11-17 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in three medication carts and one medication room. Specifically the facility failed to: -Ensure medication or treatment carts were locked when the licensed nurse was not present; -Ensure multiple use vials were properly labeled; -Ensure medications were disposed of appropriately; -Ensure medication carts were maintained and clean; and, -Ensure medications were stored in an approved refrigerator Findings include: I. Manufacturer recommendations According to the Tubersol package insert, retrieved [DATE] from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. According to the Humalog package insert, retrieved [DATE] from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf vial must be used within 28 days or be discarded, even if they still contain HUMALOG. II. Facility policy and procedure…
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 before2022-11-17 · 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 the resident environment was free from accident hazards and adequate supervision was provided for one (#13) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to provide adequate supervision for Resident #13 after a fall with suspected injury on 11/14/22, to ensure he did not fall again two hours later while awaiting a mobile x-ray. Findings include: I. Facility policy The Fall Management policy, dated June 2022, was provided by the nursing home administrator (NHA) on 11/15/22 at 1:30 p.m. The policy provided in pertinent part: When a fall occurred, the resident was assessed for injury by a nurse. The nurse would enter the event information into the medical record, complete a detailed nursing progress note to include the nursing assessment and communication to the physician, family, resident and/or resident's representative, add the fall event to the 24-hour report, and initiate the interdisciplinary post…
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 · D2022-11-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure residents were kept free from unnecessary medications for three (#2, #14 and #49) of five residents reviewed for unnecessary medications out of 33 sample residents. Specifically, the facility failed to: -Have consents signed prior to psychotropic medication administration for Resident #2, #14 and #49; and, -Have behavior tracking in place for Residents #2 and #14. Findings include: I. Facility policy and procedures The Psychotropic Medication policy, undated, received from the nursing home administrator (NHA) on 11/17/22 at 6:30 a.m. read in pertinent part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. II. Resident #2 A. Resident status Resident #2, younger than 65, was admitted on [DATE].…
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
$14,901 in federal fines across 1 penalty.
- $14,901 — penalty dated 2025-08-15
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 MADISON CREEK PARTNERS — 13 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 | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 3.0 | -1.0 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 12 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHIEF JOSEPH TRAIL, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/02/2026 |
| TIPPET, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/02/2026 |
| WHITE CANYON, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/02/2026 |
| CLEGG, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 03/02/2026 |
| IKERD, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/02/2026 |
| MADISON CREEK PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2013 |
| CHRISTENSEN, COVEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2013 |
| HOPKINS, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2021 |
| SHEPHERD, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/19/2019 |
| TERRAZAS, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2022 |
CMS files one row per role, so the 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Colorado Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 065152. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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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.