Irondale Post Acute

Location & what’s nearby

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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

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.

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.

46.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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.

Staffing

How full it usually is: this home is certified for 95 beds and averages 79.2 residents a day — about 83% occupied, or roughly 16 beds typically open. It usually has some room. 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 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 2.98 hrs/resident/day on weekends vs 3.50 on weekdays — 15% thinner on weekends. RN hours go from 0.61 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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 16 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · Lcited before2025-10-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for elopement out of three sample residents and other residents residing in the facility remained as free from accidents/hazards as possible.Specifically, the facility failed to:-Ensure Resident #4 received adequate supervision to prevent the resident from eloping from the facility; and,-Ensure there was an effective evacuation plan in place and that staff were trained on the plan and provided with the necessary equipment to evacuate residents from the facility in the case of an emergency, which had the potential to affect the safety of all 72 residents residing in the facility.ELOPEMENT INCIDENT FAILURE FOR RESIDENT #4Resident #4, who had diagnoses of bipolar disorder, cognitive communication deficit, chronic heart failure, presence of automatic implanted cardiac defibrillator and traumatic subarachnoid hemorrhage (bleeding between the brain and the protective layer of the brain), was admitted…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-04-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#3) of eight residents reviewed for accidents received adequate supervision out of eight sample residents. Specifically, the facility failed to ensure Resident #3 was provided safe transportation. Resident #3 was wheelchair bound and dependent on staff for mobility and positioning. She had functional limitations in range of motion for her lower extremities due to below the knee amputations. Resident #3 was assisted into the van after an appointment on 1/22/25 by van driver #1. Resident #3 was not secured properly in the van. When the van accelerated, Resident #3's wheelchair tipped backward and she fell onto the floor with the wheelchair landing on top of her. When van driver #1 pulled over, she noticed the resident had blood in her mouth. Emergency services were called and the resident was transported to the hospital. The resident was diagnosed with fractures of the sixth and seventh cervical vertebra, first and second…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2026-02-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one (#25) of two residents reviewed for range of motion received services and assistance to prevent a reduction in range of motion out of 35 sample residents. Resident #25 was admitted to the facility on [DATE]. According to the resident's diagnoses on admission, Resident #25 did not admit to the facility with bilateral hand contractures. On 9/9/25 a joint mobility evaluation was completed which indicated Resident #25's right wrist and right fingers had minimum range of motion limitations and left wrist and fingers had moderate range of motion limitations. He had resting bilateral hand splints and was placed on occupational therapy (OT) services for contracture management.The 11/6/25 OT discharge summary revealed the resident was placed on a restorative splint and brace program with bilateral upper extremity orthotics daily as tolerated. The prognosis to maintain the resident's current level of function was good with consistent…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of five sample residents remained free from accidents. Resident #1, who was identified as a high fall risk, sustained a fall on 9/6/24 which resulted in a hip fracture that required hospitalization. The hip fracture was not identified until 9/12/24 due to the nurse failing to report the fall. Due to the facility's failure to assess, report and identify the injury, the resident was not treated for her fractured hip for six days. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/20/24, resulting in the deficiency being cited as past noncompliance with a correction date of 9/12/24. I. Incident on 9/12/24 The nursing home administrator (NHA) and the director of nursing (DON) started an investigation of Resident #1's change of condition and her bruising on 9/12/24. The NHA and the DON reviewed camera…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2023-12-14 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#40) resident out of 36 sample residents. The facility failed to ensure Resident #40 was administered pain medication as ordered. Resident #40 was prescribed hydrocodone for pain management. The facility ran out of the scheduled prescribed medications and the resident missed seven doses of hydrocodone from 11/11/23 to 11/13/23. The facility failed to implement effective interventions to prevent the resident from running out of his medications (discovered on 11/10/23) from progressing to the resident experiencing pain, suffering withdrawal symptoms, and subsequently being administered Fentanyl by emergency medical services before being transported to the hospital and treated for pain symptoms Furthermore, the facility failed to ensure Resident #40's pain medications were ordered from…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-09-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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, interview, record review, and review of facility policies, the facility failed to ensure one (Resident #40) of three residents reviewed for nutrition maintained his/her body weight and did not sustain severe weight loss. Specifically, on 07/05/2022 the resident weighed 180.4 pounds and on 07/30/2022, Resident #40 weighed 159 pounds, a 21.4 pound or 11.86 percent (%) weight loss in 25 days. The failed to identify and address Resident #40's severe weight loss. Findings included: A review of the facility's Tracking Weight Changes policy/procedure, dated August 2019, revealed A copy of weight records will be forwarded to the appropriate professional each month. The RD or designee will review monthly weights and calculate significant change over one, three, and six months. The RD or designee will review all significant weight losses, and assess for insidious weight loss as well. The RD or designee will make referrals and take action as necessary (including follow up documentation). A review of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a comfortable and homelike environment in one of four units. Specifically, the facility failed to: -Ensure all residents' rooms in the secured unit were in good repair; -Ensure the small common area of the secured unit was free from unpainted areas on the walls, free of sheet rock damage and missing floor tiles; and, -Ensure the dining room area of the secured area was free from stains in the ceiling and free of sheet rock damage.Findings include: I. Facility policy and procedure The Safe Homelike Environment policy, revised December 2020, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:24 p.m. It revealed in pertinent part, The facility provides a safe, clean, comfortable and homelike environment.II. Observations On 2/12/26 at 9:00 a.m. an environmental tour of the secure unit was conducted. The small common area at the secure unit entrance doors was observed to have multiple black marks on the ceiling. There were…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that two (#51 and #12) of four residents reviewed for abuse out of 35 sample residents were kept free from physical abuse.Specifically, the facility failed to protect Resident #51 and #12 from abuse towards each other.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised December 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated. When an incident or suspected incident of abuse or neglect is reported, the administrator or designee investigates the incident with the assistance of appropriate personnel. A licensed nurse examines the resident upon receiving reports of alleged physical or sexual abuse and records findings in the resident's 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 protect one (#27) of three residents from misappropriation of property out of 35 sample residents. Specifically, the facility failed to prevent Resident #27 from having a significant amount of money stolen from his room.Findings include: I. Facility policy and procedureThe Abuse Investigation and Reporting policy and procedure, revised 12/22/25, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated.II. Incident of misappropriation of property for Resident #27 A. Facility investigation The 12/24/25 grievance form revealed the resident reported that he had $700.00 missing from his room. The resolution was the former social services director (SSD) would follow up with Resident #27. Resident #27 said the money had been missing since a week ago (12/17/25)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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 were free from chemical restraints for one (#8) of five residents out of 35 sample residents. Specifically, the facility failed to ensure Resident #8's continued use of an antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary team (IDT) for continued medical necessity and gradual dose reduction (GDR).Findings include:I. Facility policy and procedure The Chemical Restraints and Psychotropic Medication Management policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 2/9/26 at 3:59 p.m. It read in pertinent part, Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Quarterly thereafter, or with any significant change in condition, the residents will be calendared by the social services director for interdisciplinary…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for three (#51, #12 and #27) of six residents out of 35 sample residents.Specifically, the facility failed to:-Complete a thorough investigation after an allegation of physical abuse between Resident #51 and Resident #12; and,-Thoroughly investigate an allegation of misappropriation of property involving Resident #27.Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised December 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated. When an incident or suspected incident of abuse or neglect is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0679 — failed to provide activities — isolated
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to implement activity programs that met the interests and supported the physical, mental, and psychological well-being of one (#12) of 19 residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to offer and provide a personalized activity program for Resident #12.Findings include:I. Facility policy and procedureThe Activity Policy and Procedure Manual, dated December 2024, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate.Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations: Cognitive impairment (task segmentation, settings that recreate past experiences, smaller groups without interruption, one-to-one); Language barrier…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#25) of three residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to:-Obtain accurate wound care orders for Resident #25 in a timely manner; and, -Ensure interventions were followed for Resident #25 to prevent an abrasion to the resident's back.Findings include:I. Facility policy and procedure The Wound Care and Treatment Guideline policy and procedure, revised May 2024, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:24 p.m. It read in pertinent part, Treatments will be placed in the electronic medical record (EMR), treatments can be triggered under the EMAR (electronic medication administration record) or TAR (treatment administration record). A licensed nurse will monitor the wounds with treatments and scheduled assessments. Treatments will be placed 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0685 — isolated
  Assist 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 observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#13) of two residents reviewed for hearing and vision problems out of 35 sample residents.Specifically, the facility failed to ensure Resident #13 was assisted to receive a replacement hearing aid after her hearing aid was broken.Findings include:I. Facility policy and procedureThe Hearing and Vision Services policy, revised January 2022, was provided by the nursing home administrator (NHA) on 2/12/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social services designee is responsible for assisting residents and their families in locating and utilizing any available resources for the provision of the vision and hearing services the resident needs.II. Resident #13A. Resident statusResident #13,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-12 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of three medication carts and one of three medication refrigerators.Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart and disposed of; and,-Ensure the medication refrigerator was securely locked on one of three units.Findings include:I. Professional referencesThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24), was retrieved on 2/13/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-08 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#2) of four residents reviewed out of seven sample residents.Specifically, the facility failed to ensure Resident #2 received his tube feeding administration as ordered by the physician. Findings include:I. Resident #2A. Resident status Resident #2, age [AGE], was admitted on [DATE] and discharged on 11/1/25 to the emergency department via ambulance. According to the November 2025 computerized physician orders (CPO), diagnoses included pneumonia, muscle weakness, acute respiratory failure, dysphagia oropharyngeal phase (difficulty swallowing), protein calorie malnutrition and cerebral infarction (a blood clot in artery in the brain that cuts off oxygen and nutrients to the brain). The 10/29/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for a mental status (BIMS) score of 13 out of 15. He required…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$131,261 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $50,400 — penalty dated 2026-02-12
• $30,076 — penalty dated 2025-10-09
• $17,345 — penalty dated 2025-04-30
• $8,338 — penalty dated 2024-11-20
• $25,102 — penalty dated 2023-12-14
• Medicare payment denial — starting 2024-01-13 for 32 days

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

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

CMS files one row per role, so the 15 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 84% 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 $925K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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