Berkley Manor Care Center
735 S Locust St, Denver, CO 80224 · For profit - Limited Liability company · 118 certified beds · (303) 320-4377 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (14% vs 45% nationally) — better care continuity
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,160 in federal fines (most recent 2023-11-30)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 improved from 4 to 5 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 | 13.8% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 12.2% | 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 | 0.4% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.4% | 8.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 11.6% | 13.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 5.6% | 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 | 3.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.9% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.1% | 20.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.0% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 33.8% | 20.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.9% | 12.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.37 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.35 | 1.74 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 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 | 10.8%CMS range 6.6–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 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 | 81.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 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 | 0.95 | 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 118 beds and averages 72.8 residents a day — about 62% occupied, or roughly 45 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.39 hrs/resident/day on weekends vs 3.89 on weekdays — 13% thinner on weekends. RN hours go from 0.97 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 14% is below 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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2023-11-30 · 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 observation, interviews, and record review, the facility failed to assess and monitor an existing pressure injury for one (#50) of seven residents reviewed for wounds out of 32 sample residents and failed to take steps to prevent the resident's development of pressure injuries. Resident #50 who required hands on assisance from staff to complete activities of daily living such as toileting, bed mobility, dressing and personal hygiene and who was at high risk for developing pressure injuries developed facility acquired pressure injury. The resident's pressure injury was first discovered on 4/27/23 and started as a redness spread over the bony part of the resident's left hip. The wound care physician classified the wound as a trauma wound. There was no documentation in the resident's chart to identify what type of trauma caused the wound to develop other than the resident lying on the hip creating skin damage for pressure to the wound site. A note written by the facility's occupational therapist (OT)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2022-08-11 · 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 staff interviews, the facility failed to ensure two (#54 and #4) of four residents reviewed for accident hazards out of 34 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of accidents. Resident #54 was admitted to the facility on [DATE] with a diagnosis and history of falls. The resident had four falls from 8/23/21 through 4/7/22. The facility failed to implement effective fall precautions with her risk of falling. On 4/7/22 the resident sustained a head injury following a fall which required hospital treatment. The interventions included educating the resident but also documented the resident was not always able to communicate her needs and that she forgot conversations held after a few minutes. The resident had a care plan to wear non-skid socks. During the survey from 8/8/22 to 8/11/22, the resident was observed walking the hallway in nylon material socks that were not non-skid. In addition, 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 · F2026-02-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the upstairs kitchen. Specifically, the facility failed to:-Ensure dietary staff performed appropriate hand hygiene during meal service; and,-Ensure the rims of cups were not touched by staff when serving beverages. Findings include:I. Failed to ensure dietary staff performed appropriate hand hygiene during meal serviceA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 3/3/26. It revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue;…
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 F0849 — patternArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 meet all requirements for the provision of hospice care for three (#3, #58 and #33) of three residents reviewed for hospice services out of 41 sample residents. Specifically, the facility failed to ensure hospice notes were readily accessible and the comprehensive care plan was developed with delineation of care responsibilities established between the facility and hospice for Resident #3, Resident #58 and Resident #33.Findings include: I. Facility policy and procedure The Hospice policy and procedure, revised 9/3/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part The facility provides hospice care under a written agreement and must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the long-term care (LTC) facility to attain or maintain the resident's highest practicable physical, mental, 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.
- Potential for harm · Ecited before2026-02-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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 cleaned and disinfected residents' rooms in a hygienic manner; -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents' rooms; -Ensure a urine spill in the dining room was cleaned and disinfected in an appropriate manner; and,-Ensure urinary catheter bags were stored in a sanitary manner in residents' rooms.Findings include:I. Failed to ensure housekeeping staff cleaned and disinfected residents' rooms in a hygienic manner and performed appropriate hand hygiene while cleaning residents' roomsA. Professional referenceThe Centers for Disease Control and Prevention's (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 3/2/26 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.
- Potential for harm · D2026-02-26 · 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, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene for one (#23) of four residents reviewed for services to maintain the highest practicable quality of life out of 41 sample residents.Specifically, the facility failed to ensure Resident #23 received timely incontinence care.Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADL) policy, dated 9/4/24, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.II. Resident #23A. Resident statusResident #23, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included nondisplaced fracture of the body of the right calcaneus (a break in the right heel bone where the bone…
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 F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 clarify resuscitation choices and document them accurately in the medical records for two (#53 and #11) of two residents reviewed for advance directives out of 41 sample residents.Specifically the facility failed to:-Ensure Resident #53 and Resident #11's medical orders for scope of treatment (MOST) forms matched their physician's orders; and,-Ensure staff were able to locate the residents' MOST forms in order to follow the residents' choices for cardiopulmonary resuscitation (CPR).Findings include: I. Facility policy and procedure The Advance Directives and Advance Care Planning policy, reviewed [DATE], was received from the nursing home administrator (NHA) on [DATE] at 12:03 p.m. It read in pertinent part, Social services ensures that a copy of the advance directive is obtained for the resident's medical record and verifies that there is an appropriate physician's order in the resident's medical record as well. This review should focus on if 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 F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 communicate effectively with the dialysis centers for two (#61 and #4) of two residents reviewed for dialysis out of 41 sample residents.Specifically, the facility failed to ensure dialysis communication forms between the facility and the dialysis center were thoroughly completed consistently for Resident #61 and Resident #4.Findings include: I. Facility policy and procedure The Hemodialysis Offsite policy and procedure, revised on 9/16/25, was provided by the nursing home administrator (NHA) on 2/27/2 at 3:54 p.m. It revealed in pertinent part, The facility assures that each resident receives care and services for the provision of offsite hemodialysis consistent with professional standards of practice, which includes: arrangements for safe transportation to and from the dialysis facility; ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments at a certified dialysis 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 · D2026-02-26 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional standards or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#40) of two residents reviewed for trauma-informed care out of 41 sample residents. Specifically, the facility failed to ensure Resident #41 had a trauma-informed care plan which identified potential triggers that had the potential to re-traumatize the resident.Findings include:I. Facility policy and procedureThe Trauma-Informed Care policy and procedure, revised 1/6/26, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, Based on the comprehensive assessment of a resident, this facility ensures that residents who are diagnosed with mental disorder and psychosocial adjustment difficulty, or…
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 record review and interviews, the facility failed to ensure one (#17) of one resident out of 41 sample residents received dental services timely. Specifically, the facility failed to assist Resident #17 with finding another dental service that accepted his dental insurance.Findings include:I. Facility policy and procedureThe Dental Services policy and procedure, reviewed 9/3/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, The facility is responsible for assisting the resident in obtaining needed dental services, including routine dental services. The facility will provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident. Residents will be assisted with making appointments and arranging transportation to and from the dentist's office if necessary.II. Resident #17 A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician…
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 F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for one (#36) of five residents reviewed for immunizations out of 41 sample residents. Specifically, the facility failed to ensure Resident #36 received pneumococcal immunization when consent was given.Findings include:I. Professional Reference According to the Centers for Disease Control and Prevention's (CDC) Pneumococcal Vaccination, revised 2/25/26, retrieved on 3/2/26 from https://www.cdc.gov/pneumococcal/vaccines/index.html, CDC recommends pneumococcal vaccination for all adults 50 years or older.II. Facility policy and procedureThe Vaccination of Older Adults policy, revised 1/28/25, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, Consents and declinations should be captured using an informed consent form for the vaccine.Education, assessment findings, administration, refusal or did not receive due…
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 before2023-11-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 and labeled in one of two medication storage rooms. Specifically, the facility failed to ensure vaccines and insulins (medications used to regulate blood glucose levels) were not stored in a dormitory style fridge. Findings include: I. Professional reference According to the Vaccine storage and Handling Toolkit retrieved on 11/30/23 from: https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf it revealed in pertinent part Do not store any vaccines in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units pose a significant risk of freezing vaccines, even when used for temporary storage. II. Facility policy and procedure The Storage and Expiration Dating of Medication, Biologicals policy, revised 7/21/22, was received from the nursing home administrator (NHA) on 11/30/23 at 12:50 p.m. It revealed in pertinent part, facility should ensure that medications and biologicals were stored at their…
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 17 citations
- Potential for harm · Dcited before2023-11-30 · 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
Based on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure the soiled linen laundry room exhaust fan was functional. Findings include: I. Observations An observation of the soiled linen laundry room was completed on 11/30/23 at 10:45 a.m. An exhaust fan was installed in the ceiling of the soiled linen laundry room. The fan was not audible and did not create air movement with the switch turned on. The fan was covered with thick gray and black debris. As a measure of checking the function of the fan, a small square of single ply toilet paper was placed against the vent. The exhaust fan was unable to hold the toilet tissue in place which indicated the fan did not function properly. -Soiled linen odors such as urine were observed during multiple observations in the soiled linen laundry room. The soiled linen laundry room exhaust fan was not functional. II. Staff Interview The environmental tour was conducted with the director of maintenance (DM) 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.
- Potential for harm · Fcited before2022-08-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 in two of two floors. Specifically, the facility failed to: -Ensure visitors and staff who entered into the facility through the front lobby, reception area, wore masks; -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; -Ensure resident bedrooms were cleaned with proper infection control techniques. The housekeeping staff wore the same gloves to clean rooms with double occupancy, and used the same cleaning rag throughout a double occupancy room; and, -Ensure proper personal protective equipment (PPE) were donned and doffed properly. Findings include: I. Facility policy The Infection Prevention and Control Program (IPCP) and Plan, revised 6/7/22, was provided on 8/11/22 at 8:30 a.m. by the director of nursing…
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 · E2022-08-11 · 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 and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 26 of 53 resident rooms, six of six hallways. Specifically, the facility failed to ensure walls, baseboard cove, doors, floor tiles, and ceiling were repaired, painted and properly maintained: and failed to ensure resident's had clean bath linens. Findings include: A. Initial observations Observations of the resident living environment conducted on 8/10/22 at 3:00 p.m. revealed: room [ROOM NUMBER]: The bedside table had water damage with a two inch gap of saturated wood all the way around the table exposing the metal underneath. The wall underneath the television had four large nails sticking out of the wall. The resident did not have any towels next to her sink. room [ROOM NUMBER]: The heater vent behind the resident's bed was damaged from the bed being lifted and lowered. The four inch ceiling border along the top of the walls was missing throughout the entire room. 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 · E2022-08-11 · tag F0685 — patternAssist 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 vision and hearing abilities for two (#37 and #14) of two residents out of 34 sample residents. Specifically the facility failed to provide services to fix broken glasses for Resident #37 and #14. Findings include: I. Facility policy The Vision and Hearing Assistive Devices policy, revised 8/31/21, was provided by the director of nursing (DON) on 8/11/22 at 8:30 a.m. It revealed in pertinent part: Ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Assistive devices to maintain vision include but are not limited to, glasses, contact lenses, magnifying lens or other devices that are used by the resident. The facility will assist as needed with making appointments and arranging transportation to obtain needed services. In situations where the resident has lost their device, the facility must assist residents and their…
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 · E2022-08-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 resident and staff interviews and record review, the facility failed to assist residents with either maintaining continence or ensuring appropriate treatment to restore continence to the extent possible for two (#14 and #46) of two residents reviewed of 34 sample residents. Specifically, the facility failed to offer and encourage Resident #14 and Resident #46 a toileting program to promote bladder continence. Findings include: I. Facility policy The Incontinence Management policy, revised 11/19/21, received from the nursing home administrator read in pertinent part, conduct a comprehensive, interdisciplinary review and assessment of the resident's continence status of admission, quarterly and with significant change of urinary function including factors that predispose the residents to the development of urinary incontinence and the use of indwelling catheter.Encourage the resident to void regularly for example every 2 hours, when the resident can stay dry, for two hours, increase the intervals by 30…
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 · E2022-08-11 · tag F0744 — failed to care for residents with dementia — patternProvide 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 record review and interviews, the facility failed to ensure residents who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#54 and #33) of three residents out of 34 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #54 and Resident #33. Findings include: I. Census and Conditions demographic The 8/8/22 Census and Condition form documented that 62 total residents resided at the facility. The form further documented there were 16 residents with a dementia diagnosis and six residents with behavioral healthcare needs. II. Professional reference The Gerontologist (February 2018), retrieved from on 8/22/22: https://academic.oup.com/gerontologist/article/58/suppl_1/S1/4816759?login=true The Alzheimer's Association Dementia Care Practice Recommendations included the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-11 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 its medication error rate was not five percent or greater for observed medication administration. Specifically, the facility had a medication error rate of 6.9%, which was two errors out of 29 opportunities for error. Findings include: I. Professional standard According to [NAME], [NAME] and [NAME], (copyright 2017), Fundamentals of Nursing (ninth edition), page 614, it read in part, Safe drug administration involves adherence to prescribed doses and dosage schedules. Follow the medication administration policies of your agency about the timing of medications to ensure that you administer medications at the right time. II. Facility policy The General Dose Preparation and Medication Administration policy and procedure, effective revised on 1/1/22, was provided by the facility nurse consultant (FNC) on 8/11/22 at 6:15 p.m. It included in pertinent part, facility staff should verify that the medication name and dose are correct…
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 before2022-08-11 · 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 and labeled in two medication carts and one storage room. Specifically, the facility failed to ensure: -Medication or treatment carts were locked when the licensed nurse was not present; -Topical medications were labeled; -Topical medications were not stored on nurses desk; -Food was not stored in the medications storage areas; and, -Disinfectant was kept separate from medication. Findings include: I. Facility policy and procedure The General Dose, Preparation and Medication Administration, dated 1/1/22,, provided on 8/11/22 at 6:15 p.m. from the facility nurse consultant (FNC) read in pertinent part, Facility staff should not leave medication or chemicals unattended. Facility should ensure that all medication carts are always locked when out of sight or unattended. The Storage and Expiration Dating of Medications, Biologicals policy, revised 1/1/22, was provided by the director of nursing (DON) on 8/9/22 at 2:13 p.m. read in pertinent part, Facility should ensure that…
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 · E2022-08-11 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers for COVID-19. Specifically, the facility failed to ensure: -Rapid point-of-care (POC) tests for COVID-19 were consistently conducted on staff prior to the start of their shift, based on the facility's county positivity rate; and, -Staff implemented correct testing techniques with PCR (polymerase chain reaction) testing to ensure accurate results. Findings include: I. Professional reference The Healthcare Community Transmission Levels for the facility's county of residence, obtained from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels, were reviewed for the time of survey (8/8/22-8/11/22) and found to be in High levels of transmission. The Centers for Disease Control and Prevention (updated 2/2/22), Interim Infection Prevention and Control Recommendations to prevent SARS-CoV-2 Spread in Nursing Homes COVID-19 Nursing Homes, retrieved on 8/11/22 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.
- Potential for harm · Ecited before2022-08-11 · tag F0923 — patternHave 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
Based on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning on three of six resident hallways. Findings include: A. Observations An observation of the resident environment was completed on 8/10/22 at 3:00 p.m. Exhaust fans were installed in the ceiling of each bathroom. Bathroom fans in rooms located on the 100 and 200 hall were not audible and did not create air movement with the switch turned on. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans did not function properly. Urine odors were observed during multiple observations in the 100 and 200 hall, between 8/8/22 and 8/11/22. The bathroom exhaust fans in rooms #127, #125, #123, #122, #121, #118, #210, #212, #209 and #227 were not functioning. B. Staff Interview The environmental tour 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 · D2022-08-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 each resident had the right to formulate an advanced directive for three (#46, #54 and #4) of 24 residents reviewed out of the 34 sample residents. Specifically the facility failed to: -Ensure advanced directives for Residents #46, #54, and #4 were completed accurately. The facility utilized the medical orders for scope and treatment (MOST) for the resident's advance directives; -Have Resident #46 sign his advance directive as he was his only power of attorney: and, -Have a legal signature on Resident #54's advance directives when a physician designated a family member as the resident's authorized representative. Findings include: I. Professional reference According to the Colorado Advance Directives Consortium, Guidance for Health Care Professionals website, 2022 accessed online 8/15//22 from https://www.coloradoadvancedirectives.com the new Colorado MOST, effective [DATE]; The MOST is primarily intended for elderly, chronically, or seriously…
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 · D2022-08-11 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed provide care and services for activities of daily living including speech, language and other communication systems for one (#14) out of 34 sample residents. Specifically, the facility failed to: -Ensure Resident #14 was able to communicate in her preferred language; and, -Ensure the communication book was available at Resident #14's bedside. Findings include I. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO) diagnoses included,type 2 diabetes mellitus with hyperglycemia, abnormal posture, and chronic kidney disease stage three. According to the minimum data assessment (MDS) dated [DATE] coded as being cognitively intact with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with activities of daily living. The resident spoke Spanish as a primary language. II. Resident interview and observations…
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 · D2022-08-11 · 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 staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#62) of five residents reviewed for activities out of 34 sample residents. Specifically, the facility failed to ensure Resident #62 was invited and encouraged to attend activities of her preference. Findings include: I. Facility policy and procedures The Therapeutic Activities Program policy and procedure, revised 11/2/21, was provided on 8/10/22 at 12:20 p.m., by the nursing home administration (NHA). It read in pertinent part, Directing the activity program includes scheduling of activities, both individual and groups, implementing and or/delegating the implementation of the programs, monitoring the response and/or reviewing/evaluating the response to the programs 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 · D2022-08-11 · 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 resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#17) of two residents reviewed for supplemental oxygen use out of 34 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #17. Findings include: I. Facility policy and procedures The Oxygen Administration/Safety/Storage/Maintenance policy and procedure, revised 8/8/21, was provided on 8/11/22 9:18 a.m., by the director of nursing (DON). It read in pertinent part, ' To assure that oxygen is administered and stored safely within the healthcare centers or in an outside storage area. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included fracture of right femur (hip), diabetes mellitus, and fracture of lateral condyle of left femur, history of falls, depression 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.
- Potential for harm · D2022-08-11 · 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 record review and interviews, the facility failed to provide effective pain management services to one (#13) of 34 sample residents. Specifically, the facility failed to try more than one non-medication pain management interventions for Resident #13. I. Facility policy The Pain policy, revised on 7/17/21, was delivered by the nursing home administrator (NHA) on 7/16/22 at 10:40 a.m. It read in pertinent part: The purpose of pain assessment and management is to help residents maintain their highest practicable level of well being by managing pain indicators. Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident ' s choices related to pain management. All residents will be assessed for pain indicators upon admission/readmission. An individualized pain care plan will be developed and reviewed and revised by the interdisciplinary team 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.
- Potential for harm · D2022-08-11 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to monitor and document mood to prevent depression difficulties for one (#12) of six residents reviewed for mood/behaviors of 34 sample residents. Specifically, the facility failed to ensure the residents behavioral needs were person centered and individualized to meet his needs for depression. Findings include: I. Facility policy and procedures The Behavior Management Pathway, no revised date, was provided on 8/10/22 at 12:20 p.m., by the nursing home administration (NHA). It read in pertinent part, Individualized approaches to care are provided as part of a supportive physical, mental and psychosocial environment, and are directed toward understanding, preventing, relieving, and /or accommodating a resident's behavioral health needs. II. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included atrial fibrillation, cellulitis (skin…
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 · D2022-08-11 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care 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 promptly provide, or obtain from an outside resource, routine and emergency dental services to meet the residents' needs for one out of 34 sample residents. Specifically, the facility failed to ensure Resident #14 received assistance to get her lower dentures repaired. Findings include: I. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders diagnoses included, type 2 diabetes mellitus with hyperglycemia, abnormal posture, and chronic kidney disease stage three. According to the minimum data assessment (MDS) dated [DATE] the resident was coded as be cognitively intact with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with activities of daily living. The MDS did not code the resident had problems with her dentures. II. Resident observations and interview Resident #14 was interviewed on 8/9/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$17,160 in federal fines across 1 penalty.
- $17,160 — penalty dated 2023-11-30
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 LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.4 | +1.6 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 5 of 5 | 3.3 | +1.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PRESTON, FORREST | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2005 |
| RUBALCABA, MARIA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2025 |
| SCHMIDT, DEREK | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 08/01/2023 |
| TSIBOAH, RITA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2022 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 01/01/2006 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 01/01/2006 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 01/01/2006 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2005 |
| ABUABA, ROMANO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2025 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2021 |
| LAY, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/24/2017 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/27/2024 |
| SWANKER, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2022 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/18/2001 |
CMS files one row per role, so the 22 rows in the source record cover these 14 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.
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 78% 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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
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 065223. 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 →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.