Yampa Valley Healthcare Center

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.

36.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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.

Staffing

How full it usually is: this home is certified for 58 beds and averages 34.4 residents a day — about 59% occupied, or roughly 24 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.43 on weekdays — 5% thinner on weekends. RN hours go from 0.93 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

40 citations, most serious first. The 20 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Kcited before2022-04-21 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 observations, record review and interviews, the facility failed to protect seven of seven residents (#19, #25, #10 and four residents who asked to remain anonymous) out of 29 sample residents, from resident-to-resident abuse that contributed to the residents experiencing emotional and psychological harm. This deficiency was cited previously during a recertification survey on 3/25/21. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Specifically, the facility failed to protect the residents from repeated instances of verbal and mental abuse by Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 toward other residents which contributed to residents feeling fearful, helpless, isolated, anxious, and stressed. Residents reported Resident #19's abusive behavior toward them triggered prior mental health conditions and a feeling that they needed 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-07 · 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 residents were kept free from accidents or hazards for one (#3) of two residents out of six sample residents.Resident #3, was admitted on [DATE] with diagnoses of cerebral vascular disease (CVA), and diabetes. Resident #3 was dependent on staff assistance for transfers using a Hoyer lift (mechanical lift). On 10/28/25, the staff were transferring Resident #3 from her bed to the shower chair using the Hoyer lift. The Hoyer lift sling came unhooked from the Hoyer lift during the transfer, which resulted in Resident #3 falling to the floor. The resident hit her head when she fell and was transferred to the hospital for evaluation. At the hospital, the resident was diagnosed with an acute parafalcine subdural hematoma (blood accumulation on the brain).Specifically, the facility failed to transfer Resident #3 safely, which resulted in the resident sustaining a brain injury. Findings include:Record review and interviews confirmed 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-11-25 · 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 observations, record review and interviews, the facility failed to ensure two (#26 and #5) of six residents out of 16 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #26 was admitted to the facility for long term care on 1/4/23 with diagnoses of dementia, hypotension (low blood pressure), hypokalemia (low potassium), hypothyroidism (low thyroid function) and depression. Upon admission on [DATE], Resident #26 weighed 152 pounds (lbs) and she reported she liked to eat eggs, coffee and sweets. Resident #26 had gradual weight gain until 4/12/24 when she weighed 190 lbs. At this time, the resident started gradually losing weight. On 9/4/24 the resident weighed 182 lbs. The resident sustained 12 lbs (6.5%) weight loss in one month, from 9/4/24 to 10/3/24, which was considered severe. The facility failed to implement effective person-centered nutrition interventions to address the resident's decreased oral…

  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 before2024-08-07 · 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 observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for three (#1, #2 and #3) of six residents reviewed for abuse out of six sample residents. Resident #1, who had a diagnosis of Alzheimer's disease and a tendency to wander, had a plan of care which documented the resident had impaired safety awareness and wandered aimlessly. The interventions were to offer Resident #1 pleasant diversions, structured activities, food, conversation, television and card games. On 2/28/24 Resident #1 wandered into Resident #2's room. Resident #2 told Resident #1 he was in the wrong room and told him to leave. Resident #1 refused to leave the room which caused Resident #2 to push Resident #1 to the floor. A staff member, who was informed that Resident #1 went to the wrong room, rushed to the room but she was unable to open the door. Resident #1 was on the floor in front of the door and was moaning in pain. The staff member eventually opened the door. Resident #1 and…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-09 · 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 observations, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 25 sample residents. Resident #11 was at nutritional risk with diagnoses of gastroesophageal reflux disease, muscle weakness and dementia. The registered dietitian (RD) implemented measures for the resident's nutrition risk and weight. Observations during the survey revealed the resident was not provided finger foods or fortified foods at meals, a brightly colored plate and alternatives offered when Resident #11's intake was poor. The facility failed to implement nutritional recommendations at mealtimes. Furthermore, the nutritional recommendations were for the interdisciplinary (IDT) team to follow up with the physician regarding her weight loss on multiple occasions and a reweight when Resident #11 lost weight and those recommendations were not followed up on.…

  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 before2023-06-15 · 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 adequate supervision and provide assistance devices to prevent falls for one (#20) of six residents reviewed for falls out of 24 sample residents. The facility failed to ensure Resident #20, who had nine falls within six months, had effective interventions, supervision and assistance in place to prevent further falls. Resident #20 suffered multiple falls with injuries including lacerations to his face and his head, including an emergency room visit where he received six stitches and he continued to fall. Findings include: I. Facility policy The Nursing Services Policy and Procedure Manual for Long-Term Care, revised April 2018, was provided on 6/15/23 at 3:07 p.m. by the nursing home administrator (NHA). It read in pertinent part, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. II. Resident #20 A. Resident status Resident #20,…

  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 before2023-06-15 · 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 IV. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), emphysema and chronic respiratory failure with hypoxia (low oxygen level). The annual MDS assessment dated [DATE] showed the resident had a BIMS score of 14 out of 15, indicating intact cognitive status. The patient health questionnaire (PHQ) indicated depression. He had no hallucinations or delusions, but exhibited verbal behavioral symptoms directed toward others and rejected care one to three days. He needed supervision, cueing and set-up for meals. He weighed 160 pounds, his weight loss was no or unknown and he had experienced weight gain without a plan to do so. B. Record review Resident #4's physician orders as of 6/14/23 showed an order for a regular diet, regular texture, regular consistency, ordered on 8/12/19, and supplement of choice for when resident refuses meals, ordered on 1/25/23. According to the June 2023 medication administration record (MAR) 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-04-21 · 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 record review, observations and interviews, the facility failed to ensure adequate nutrition and assistance to prevent weight loss for one (#20) of five residents reviewed out of 29 sample residents. Resident #20 lost seven pounds over an eight day period, and experienced significant weight loss. Resident #20 had a 5% weight loss from 2/7/22 to 2/21/22 and a 7.5% weight loss from 2/7/22 to 4/19/22. The facility failed to assess and implement timely interventions, including dining assistance, to prevent the resident's significant weight loss. Findings include: I. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician orders (CPO), diagnoses included atrial fibrillation; rheumatic disorders of mitral, aortic, and tricuspid valves; and diverticulosis of intestine. The 2/10/22 minimum data set (MDS) assessment revealed that a brief interview for mental status (BIMS) assessment was not completed as the resident was rarely understood. The MDS…

  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 before2022-04-21 · tag F0742 — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#19) of two out of 29 sample residents, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to implement effective interventions for Resident #19 to prevent and appropriately address Resident #19 abusive behaviors towards other residents. The facility failed to protect residents from continued verbal and mental abuse from Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 towards other residents, resulting in feelings of fear, helplessness, social isolation, humiliation, and extreme anxiety. The staff failed to document the all of Resident #19 behavior, creating a limited management awareness of the frequency of the behaviors towards residents. The facility provided staff education on behavior management but the trainings did not improve the hostile living environment that the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-04-21 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide person-centered dementia care to five (#33, #14, #15, #29 and #91) of five residents reviewed out of 13 residents who resided on the dementia care secured unit (SCU). Resident #33 had dementia with lewy bodies and behavioral symptoms including repetitive verbalizations that affected her well-being and that of others around her. She had delusions and hallucinations, and talked loudly and often cursed to herself, causing other residents' anxiety to escalate. Resident #16, who was typically very quiet, walked by Resident #33 when she was cursing, yelled at her to shut the (obscenity)! and charged toward her. He would have possibly injured Resident #33 had a staff person not stepped between them and redirected him, apologizing and explaining that Resident #33 was not talking to him. The facility failed to address Resident #33's behavioral symptoms in a manner that effectively calmed and soothed her, and prevented psychosocial harm 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 residents were free from accidents or hazards for three (#2, #5 and #3) of eight residents reviewed out of eight sample residents. Specifically, the facility failed to:-Implement interventions to prevent an elopement for Resident #2 and;-Implement fall interventions for Resident #5 and Resident #3.Finding include: I. Elopement failures A. Facility policy and procedure The Wandering and Elopement policy, revised March 2019, was provided by the director of nursing (DON) on 9/30/25 at 3:26 p.m. It revealed in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. B. Resident #2 1. Resident status Resident #2, age greater than 65, was…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · 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 Received treatment and care in accordance with professional standards or practice out of eight sample residents.Specifically, the facility failed to:-Complete a wander risk assessment after Resident #1 had a change of condition and left the building;-Obtain physician's orders for the use of Resident #1's wanderguard; and, -Ensure Resident #1's care plan was updated with the use of a wander guard. Findings include:I. Facility policy and procedureThe Wandering and Elopement policy, revised March 2019, was provided by the director of nursing (DON) on 9/30/25 at 3:26 p.m. It revealed in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.II. Resident #1A. Resident statusResident #1, age less than 65, 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
• Potential for harm · E2025-08-05 · tag F0561 — failed to honor residents' choices — pattern
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  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 honor resident choices for six (#4, #10, #11, #14, #15 and #18) of 10 residents reviewed out of 18 sample residents.Specifically, the facility failed to offer Resident #4, Resident #10 and Resident #11, Resident #14, Resident #15 and Resident #18's preferred community activities outside of the facility. Findings include:I. Resident #4A. Resident statuResident #4, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included acquired absence of the left leg (above the knee), neuromuscular dysfunction of the bladder, Spina Bifida and Osteochondrodysplasia (a genetic disorder affecting the legs). The 3/31/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with repositioning, transfers, toileting, dressing and showering.B. Resident interviewResident #4…

  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 · F2024-11-25 · tag F0801 — widespread
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  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 designate a person to serve as the director of food and nutrition services who was a qualified dietitian, certified dietary manager (DM), or a certified food service manager. Specifically, the facility failed to employ a qualified DM or have a full time registered dietitian (RD). Findings include: I. Observations The 11/4/24 at 11:37 a.m. kitchen tour revealed there was no dietary manager (DM) currently employed at the facility. II. Record review -The facility was unable to provide documentation that indicated there was an individual that was employed by the facility that was a qualified dietary manager. II. Staff interviews The nursing home administrator (NHA) was interviewed on 11/4/24 at 12:04 p.m. The NHA said the facility did not have a DM. She said the facility was advertising this open position, however at that moment there were no candidates that had applied for the job. She said the registered dietitian (RD) was on a consultant basis and came to the facility two times a month. The cook (CK) and 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-11-25 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 housekeeping staff followed proper infection control procedures for cleaning resident rooms. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 11/7/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty,…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-25 · 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 in accordance with accepted professional standards for one of one medication refrigerator. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 11/6/24 at 3:40 p.m. It read in pertinent part, Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. II. Observations On 11/5/24 at 11:09 a.m., the medication refrigerator was observed with licensed practical nurse (LPN) #1. Two vials of liquid Ativan (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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure five (#3, #13, #20, #10 and #9) of six residents reviewed for activities of daily living (ADLs) out of 25 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Residents #33, #13, #20, #10 and #9, who were dependent on staff for bathing care, were provided bathing consistently with their plan of care. Findings include: I. Resident #3 A. Resident status Resident #3, under age [AGE], was admitted on [DATE]. According to the February 2024 computerized orders (CPO), diagnoses included chronic pain, hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following cerebral infarction (stroke) that affected her left side. The 11/4/23 minimum data (MDS) assessment showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS). 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide 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 interviews, observations and record review, the facility failed to ensure three (#25, #3 and #10) of three out of 25 sample residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to ensure oxygen concentrators had distilled water to humidify the oxygen concentrators for Resident #25, #3 and #10. Findings include: I. Professional reference According to the [NAME] Advantage for Basic Nursing handbook, third edition, retrieved from Treas, [NAME] S., et al. [NAME] Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. [NAME] Company, 2022., Key concepts of administering oxygen included, in relevant part, Attach the flow meter to the oxygen source. Attach the humidifier to the flow meter. The humidifier is a small plastic container containing normal saline. The humidifier adds moisture in with the oxygen, which can dry the nasal or oral cavity. II. Facility policy and procedure The Oxygen Administration…

  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 · E2024-02-09 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference citations: -F677 activities of daily living for dependent residents; and, -F689 accident hazards. Findings include: I. Resident care needs The facility census was 38 residents. Licensed practical nurse (LPN) #2 was interviewed on 2/9/24 at 10:30 a.m. LPN #2 said there were two residents who required a two person transfer using a mechanical Hoyer lift. She said there were five residents who required extensive assistance with eating. She said out of the 38 residents there were only five residents who required minimal…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-09 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#10 and #14) of two residents reviewed for medication errors out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #10 was administered her chronic obstructive pulmonary disease (COPD) medications ordered for nearly a week; and, -Resident #14 was administered his medication for Huntington's disease. Findings include: I. Facility policy and procedure The Medication Ordering and Receipt policy and procedure, dated 6/21/17, was provided by the director of nursing (DON) on 2/8/24 at 8:57 a.m. It documented in pertinent part, Non-dose bulk medications such as inhalers, liquids, creams, and patches must be reordered by the facility when there is no more than a four day supply of medication remaining. II Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$120,965 in federal fines across 3 penalties.

• $54,990 — penalty dated 2024-11-25
• $36,660 — penalty dated 2024-08-07
• $29,315 — penalty dated 2024-02-09

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.

Who owns this facility

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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 75% 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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