Briarwood Health Care 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.

44.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 201 beds and averages 88.4 residents a day — about 44% occupied, or roughly 113 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.52 hrs/resident/day on weekends vs 4.05 on weekdays — 13% thinner on weekends. RN hours go from 0.80 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 44% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

22 citations, most serious first. The 15 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-05-09 · tag F0880 — failed to prevent and control infections — isolated
  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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observations and interviews revealed the nursing staff lacked the knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters (glucometer) according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized and stored properly in between each resident's use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. One resident who shared the glucometer with another had a diagnosis of chronic…

  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
• Actual harm · G2025-07-16 · tag F0760 — failed to prevent significant medication errors — isolated
  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 one (#5) of 12 residents reviewed for medication management were free from significant medication errors out of 12 sample residents. Resident #5 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain) and epilepsy (seizure disorder).On 6/7/25 the facility received a delivery from the pharmacy. Licensed practical nurse (LPN) #1 signed for the delivery and did not open the box to check the contents. LPN #1 placed the box in the medication room. When LPN #1 went to administer Resident #5's Dilantin medication (a medication used to prevent seizures) on 6/20/25 and 6/21/25, she was unable to locate the medication. This resulted in Resident #5 missing three consecutive doses of Dilantin. On 6/21/25 Resident #5 was transferred to the hospital for a possible seizure. The resident 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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2022-03-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#58) of four residents reviewed for range of motion (ROM) and mobility out of 26 sample residents received appropriate treatment and services to prevent further decrease in ROM and mobility. Resident #58 admitted to the facility for long term care on 11/8/21 with diagnoses of muscle weakness, abnormality of gait and mobility, dysphagia (difficulty swallowing) and lack of coordination. The resident required staff assistance with activities of daily living (ADLs) and was admitted to the facility with a contracture in his right hand (as indicated by staff interviews and minimum data assessment 11/12/21). The facility failed to assess, provide services to maintain or improve his ADLs to include his swallowing function. The facility failed to assess the level of the resident's contracture and whether his hand/s had worsened during his stay at the facility. Recommendations from the restorative certified occupational therapy…

  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 · G2022-03-15 · 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 interviews and record review the facility failed to ensure the environment was free of accidents and hazards and failed to provide adequate supervision and assistance to prevent an accident for one (#25) of four out of 26 sample residents. Resident #25 had a known history of elopement and wandering behaviors. Resident #25 often verbalized she was looking for something in attempts to leave the unit. The facility failed to implement measures to ensure her safety with her wandering, attempting to leave the unit and history of elopement. Resident #25 was assisted on 2/23/22 by a male resident to the elevator at around 9:45 p.m. where he reported to staff he sent the resident down on the elevator. The facility staff began looking for her on the unit and other units. About an hour and 15 minutes later, Resident #25 was found in the boiler room in the basement of the facility. When Resident #25 was found at 11:00 p.m. she had complaints of right arm pain, a large hematoma was located on her elbow and her right…

  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 · G2022-03-15 · 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 Based on observations, interviews, and record review, the facility failed ensure one (#58) of five out of 26 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #58 admitted to the facility for long term care on 11/8/21 with diagnosis of malnutrition and dysphagia (swallowing trouble). The resident had a BMI of 16.6 (underweight being 18.5 or less) when he was admitted to the facility, which indicated he was underweight. The resident had a loose fitting bottom denture causing chewing difficulty. According to the registered dietitian, she was aware the resident had weight loss prior to being admitted to the facility. The resident was at nutritional risk due to previous weight loss, malnutrition and with swallowing trouble. According to the resident's primary care physician, the resident had sustained weight loss but had increased intake when he ate with his family or had the food the family brought in for him,…

  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 · D2024-10-03 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  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, interview, and review of facility policy, the facility failed to ensure two residents (Resident (R)51 and R72) out two residents observed with catheter bags out of 20 sampled residents reviewed had dignity bags for their use of a foley catheter. This failure had the potential to cause embarrassment and loss of dignity to the two residents. Findings include: Review of the facility's policy, provided by the facility, titled Dignity with an issued date of 05/06/19 and reviewed on 09/25/23 revealed Each resident has the right to be treated with dignity and respect. The procedure was to promote resident independence and dignity while dining and refrain from practices demeaning to the resident, such as leaving urinary catheter bags uncovered. 1. Review of R51's Face Sheet located in the electronic medical record (EMR) under the admission Record revealed R51 was admitted to the facility on [DATE]. Review of R51's annual Minimum Data Set (MDS) located in the EMR under the MDS tab…

  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 · D2024-10-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  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 observation, interview, record review, and facility policy review, the facility failed to ensure four residents (Resident (R) 2, R6, R30, and R41) out of a total sample of 20 residents reviewed for respiratory services received appropriate care of their oxygen tubing. This created the potential for infection. Findings include: Review of the facility policy titled Oxygen Administration (Safety, Storage, and Maintenance), issued 12/03/18 and revised 02/27/24 and under the sub section titled Infection Control indicated .Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out . 1. Review of R2's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R2 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Review of R2's Physician Orders located under the Orders tab of the EMR revealed an order for…

  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 · D2024-10-03 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide 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 record review, interview, and review of facility policy, the facility failed to ensure weights were documented for one (Resident (R) 31) of two residents reviewed for dialysis out of a sample of 20 residents. This had the potential for the resident to have unmet care needs. Findings include: Review of the facility policy titled Hemodialysis Offsite Policy effective 04/24/19 and last reviewed 09/06/24 indicated that under the Procedure section revealed, the facility should weigh the resident. Under the Day of Dialysis section indicated, the facility should observe the vascular access site prior to dialysis and initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis with the resident. The Day of Dialysis section indicated on return to the facility, facility staff should obtain vital signs and complete the Pre/Post Dialysis Communication Form. Review of R31's admission Record, located in the EMR under the Profile tab, revealed R 31 was admitted to the facility on [DATE] with 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-03 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to ensure one resident (Resident (R)51) observed out of 20 sampled residents had their call light within reach. This failure had the potential to cause R51 needs to not be met . Findings include: Review of the facility's policy, provided by the facility, titled Keeping a Resident Room in Order, issued :08/09/2019 and reviewed 06/02/24 revealed The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely, call lights must be within easy reach of the resident in bed and out of bed. Review of R51's Face Sheet located in the electronic medical record (EMR) under the admission Record revealed R51 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, muscle weakness, need for assistance with care, and schizophrenia. Review of R51's annual Minimum Data Set (MDS) assessment located in…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-05-09 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control and shared glucometers, quality of care and activities to meet resident needs. Findings include: I. Facility policy The QAPI (Quality Assurance and Performance Improvement) Program Design and Scope policy, last reviewed on 10/24/22, was received from the nursing home administrator (NHA) on 5/9/23 at 6:45 p.m. The policy read in pertinent part: The facility will have a QAPI program that is ongoing, comprehensive and capable of addressing the full range of care and services it provides. At a minimum, the QAPI program will: -Address all systems of care and management practices; -Include clinical care,…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-05-09 · tag F0761 — failed to label and store drugs safely — pattern
  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 three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator; -Ensure the medication cart was locked when the nurse was not at the cart; and, -Ensure food was not stored with medications. Findings include: I. Facility policy and procedure The Storage and Expiration Dating of Medications policy and procedure, last revised on 7/21/22, was provided by the director of nursing (DON). It read in the pertinent part, Facility should ensure that only authorized facility staff, as defined by the facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other…

  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 · D2023-05-09 · tag F0659 — isolated
  Provide care by qualified persons according to each resident's written plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews the facility failed to ensure the nursing services were provided by individuals who had the skills, experience, knowledge and proper licensure to meet the residents' needs. Specifically, the facility failed to monitor unlicensed student nurses during medication administration with a resident. Findings include: I. Facility policy A request was made to the facility for a policy regarding the use of student nurses for resident care; no policy was provided during the survey. A signed contract agreement between a named educational institute for student nurses and the facility was provided by the director of nursing (DON) on 5/8/23 at 2:12 p.m. It read in the pertinent part: The facility agrees to: permit (affiliate's name) students to perform services for facility patients only when under the direct supervision of a registered, licensed or certified facility caregiver licensed in the discipline in which supervision is to be provided. Retain ultimate responsibility for the provision of all services provided to patients or residents of 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-05-09 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure 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 to ensure one (#10) of one resident reviewed for activities of daily living of 44 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #10, who spoke a language other than English. Findings include: I. Facility policy and procedure The Meaningful Communication with Persons with Limited English policy and procedure, revised 2022, was provided by the nursing home administrator (NHA) on 5/9/23 at 6:02 p.m. It documented in pertinent part, Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English may be limited English proficient (LEP). The facility will take reasonable steps to ensure that LEP residents with have meaningful access and an equal opportunity to participate in our services, activities,…

  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 · D2023-05-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  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, record review and staff interviews, the facility failed to provide appropriate care and services to maintain the activities of daily living for one (#54) of five residents who required extensive assistance out of 44 sample residents. Specifically, the facility failed to provide regular nail care for Resident #54. Findings include: I. Facility policy The Nail Care policy, revised August 2022, was provided by the nursing home administrator (NHA) #1 on 5/9/23 at 5:00 p.m. The policy read in part: The resident will receive assistance as needed to complete activities of daily living (ADLs). Any concerns with skin or nails identified during completion of nail care should be reported to the nurse who will document and report to the practitioner as needed. Ensure fingernails are clean and trimmed to avoid injury and infection. Report any abnormalities to the nurse. II. Resident #54 A. Resident status Resident #54, age [AGE], was admitted on [DATE]. According to the May 2023 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-05-09 · tag F0679 — failed to provide activities — isolated
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice 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 (#9) out of three residents reviewed for activity programming out of 44 sample residents. Specifically, the facility failed to: -Provide meaningful activities for Resident #9 while the resident was alone in her room; and, -Update the resident activity's and social program care plan with individualized meaningful person centered interventions to meet Resident #9's recreational needs and preferences. Findings include I. Facility policy and procedure The Activities Program policy, revised on 4/1/22, was received by the director of nursing (DON) on 5/10/23 at 11:50 a.m. It read in pertinent part, The facility should implement an ongoing resident centered activities program 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.

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

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

Fines & penalties

$9,110 in federal fines across 1 penalty.

• $9,110 — penalty dated 2025-07-16

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 →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 30 rows in the source record cover these 13 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 $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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