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Crestmoor Care Center

895 S Monaco Pkwy, Denver, CO 80224 · For profit - Limited Liability company · 108 certified beds · (303) 321-3110 Medicare & Medicaid certified

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Flagged for abuse1 actual-harm citation$845 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • lower-than-typical staff turnover (17% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $845 in federal fines (most recent 2025-10-02)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
850 S Monaco St Pkwy #10
Pharmacy
909 S Oneida St · (303) 355-6818 · Call to confirm hours
Grocery
890 S Monaco St Pkwy · (303) 333-1535 · Call to confirm hours
Park
6300 E Mississippi Ave · (720) 913-0668 · Typically dawn to dusk
Place of worship
925 S Niagara St · (847) 868-4096

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

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.7%13.4%15.4%better
Long-stay residents who lose too much weight4.1%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.6%1.4%2.0%better
Long-stay residents with depressive symptoms1.7%8.8%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.1%3.4%3.3%typical
Long-stay residents whose ability to walk worsened7.7%13.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.1%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine88.4%94.7%95.3%typical
Long-stay residents with pressure ulcers4.8%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control6.2%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.2%20.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.5%1.6%1.4%typical
Short-stay residents given the seasonal flu vaccine37.9%75.6%79.4%worse

§ 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.

52.9% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.9%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
0.10U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.9%CMS range 37.9–66.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.6–15.510.7%Oct 2022–Sep 2024no 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 dischargenot 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 dischargenot 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 dischargenot 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs1.011.02Oct 2022–Sep 2024CMS 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

0.82
RN hours/ resident / day
0.36
LPN hours/ resident / day
1.69
Aide hours/ resident / day
2.87
Total nurse hours/ resident / day
0.61
RN hoursweekends
17.0%
Total nursing turnover
7.1%
RN turnover

How full it usually is: this home is certified for 108 beds and averages 86.9 residents a day — about 80% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.87 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.54 hrs/resident/day on weekends vs 3.01 on weekdays — 15% thinner on weekends. RN hours go from 0.91 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 17% is below 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

11
deficiencies at the latest standard inspection (2025-02-06)
8
at the previous standard inspection (2023-08-29)

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.

ABCDEFGHIJKL

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-10-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to protect four (#12, #5, #9 and #15) of seven residents from abuse out of 12 sample residents.Resident #6 was admitted on [DATE] with a diagnosis of bipolar disorder (mental illness), depression, and dementia.Resident #12 was admitted on [DATE] with a diagnosis of dementia, other behavioral disturbance, anxiety disorder and depression.On [DATE], Resident #6 and Resident #12 were in the dining room when the residents began yelling at each other and hitting each other. On [DATE], Resident #6 grabbed Resident #12 on both of her arms. On [DATE], Resident #6 began yelling at Resident #12. Resident #6 then lunged at Resident #12 and pushed her to the ground, where she (Resident #6) attempted to hit Resident #12 in the face. As a result of the three incidents of physical and verbal abuse, Resident #12 began isolating herself and avoiding Resident #6. Resident #12 said she avoided Resident #6 when she could because Resident #6 was yelling at her,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to investigate allegations of abuse for one (#1) of five residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to complete a thorough and timely investigation after Resident #1 made abuse allegations that staff and other residents were trying to harm her. Findings include: I. Facility policy and procedure The Abuse policy, revised 2/29/24, was received from the nursing home administrator (NHA) on 6/17/25 at 12:46 p.m. It documented in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends or any other individuals. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-02-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, activities room, and two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the nourishment room refrigerators; and, -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen. Findings include: I. Failure to safely and appropriately store food items A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 2/13/25. It revealed in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-06 · tag F0880 — failed to prevent and control infections — widespread
    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 and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high-frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff performed appropriate hand-hygiene; -Ensure enhanced barrier precautions (EBP) were in place for Resident #52 and Resident #284; -Follow infection control procedures for catheter care; -Follow infection control procedures for endotracheal tube care; and, -Clean equipment between use with residents. Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-06 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for three (#15, #69 and #64) of six residents reviewed for dignity out of 47 sample residents. Specifically, the facility staff failed to treat Resident #15, Resident #69 and Resident #64 in a dignified manner. Findings include: I. Facility policy and procedure The Quality of Life - Dignity policy and procedure, revised February 2020, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. Staff are expected to treat cognitively impaired residents with…

    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 · E2025-02-06 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services for three (#80, #1 and #53) of 10 residents reviewed for ADLs out of 47 sample residents. Specifically, the facility failed to: -Provide appropriate repositioning for eating and eating supervision for Resident #80; -Provide timely eating assistance for Resident #1; and, -Provide timely repositioning, bathing and oral care for Resident #53. Findings include: I. Facility policy and procedure The Activities of Daily Living, Supporting policy, revised March 2018, was received from the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for four (#26, #31, #15 and #54) of nine residents reviewed for accident hazards out of 47 sample residents. Specifically, the facility failed to: -Ensure person-centered interventions were in place to prevent elopement incidents for Resident #26 and Resident #31; -Ensure staff provided appropriate supervision and implemented care-planned interventions for Resident #15 while smoking; and, -Ensure care-planned interventions for falls were consistently implemented for Resident #54. Findings include: I. Failed to ensure person-centered interventions were in place to prevent elopement incidents for Resident #26 and Resident #31 A. Facility policy and procedure The Elopement & Wandering policy and procedure, dated 2/29/24, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, It is a goal of the facility to provide a safe environment using…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-06 · 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 medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart; and, -Ensure injectable medications were labeled with the date they were opened. Findings include: A. Professional references The United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24), was retrieved on 2/12/25 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If…

    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 · E2025-02-06 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to: -Ensure the resident's personal refrigerator temperatures were monitored correctly for appropriate temperatures; and, -Implement the facility policy for food brought by visitors and ensure food that was kept in residents' refrigerators had safe and sanitary storage. Findings include: I. Professional reference The Colorado Retail Food Regulations, (3/16/24) were retrieved on 2/13/25. It read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. (3-501.16) Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 (#24) of one resident out of 47 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed to provide prompt resolution to grievances for Resident #24. Findings include: I. Facility policy and procedure The Grievances policy and procedure, dated 5/8/23, was provided via email by the nursing home administrator (NHA) on 2/6/25 at 8:08 p.m. It read in pertinent part, The resident, or person acting on behalf of the resident, will be informed of the investigation's findings and any corrective actions recommended, within five working days of filing the grievance or complaint. II. Resident #24 A. Resident status Resident #24, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder and postencephalitic parkinsonism (a Parkinson's disorder that develops after an inflammation to the brain). 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#77 and #69) of eight residents reviewed for abuse out of 47 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #77 from verbal abuse by Resident #23; and, -Protect Resident #69 from physical abuse by Resident #235. Findings include: I. Facility policy and procedure The Abuse Policy, dated 5/3/23, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Identification of abuse shall be the responsibility of every employee. If abuse happens: separate the assailant from the victim, isolate the assailant to protect others, assess and treat the victim, and notify the abuse coordinator. II. Incident of verbal…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-02-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#184 and #75) of seven residents reviewed for pressure ulcers out of 47 sample residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries. Specifically, the facility failed to: -Provide dressing changes for consecutive days for Resident #184, who was admitted to the facility with an unstageable pressure wound to his coccyx; -Ensure Resident #184's care plan was updated in a timely manner; and, -Provide timely wound prevention interventions and ensure interventions were consistently implemented for Resident #75, who was admitted to the facility with pressure ulcers to his coccyx and both heels. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice…

    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 · D2025-02-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#52) of four residents reviewed for catheters of 47 sample residents. Specifically, the facility failed to: -Obtain physician's orders for the use of Resident #52's catheter; -Create a care plan addressing Resident #52's use of the catheter; and, -Maintain documentation for Resident #52's catheter care and maintenance. Findings include: I. Facility policy and procedure The Urinary Catheter Care policy and procedure, revised August 2022, was received from the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The nursing and interdisciplinary team should assess and document the ongoing need for a catheter that is in place. The following documentation should be…

    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 · Fcited before2024-03-07 · tag F0761 — failed to label and store drugs safely — widespread
    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 observation and interviews, the facility failed to ensure medications and biologicals were labeled properly on four of four medication carts. Specifically, the facility failed to ensure insulin (medication used for blood glucose control) pens were labeled with the resident's name and open dates. Findings include: I. Professional reference According to the Humalin N kwikpen instructions for use, retrieved on 3/10/24 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf, Do not remove the Insulin Pen Label, unused Pens may be used until the expiration date printed on the label. II. Facility policy and procedure The Medication Labeling and Storage policy, dated February 2023, was provided regional quality mentor (RQM) on 3/6/24 at 2:00 p.m. The policy read in pertinent part, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently acceptable pharmaceutical practices. Medication labeling includes, at a minimum: the medication name, prescribed dose, strength, expiration date, resident's name,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-07 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interviews, the facility failed to perform regular control substance solution tests for four of 15 glucometers. Specifically, the facility failed to perform a control solution test on all glucometers used for monitoring resident's blood glucose. Findings include: I. Facility policy The Blood Glucose Monitoring policy, dated 10/1/2021 was provided by the regional quality mentor (RQM) on 3/7/24 at 10:45 a.m. The policy read in pertinent part, It is the policy of the facility to ensure calibration checks on glucometers must be performed per manufacturer's instructions. II. Manufacturer's recommendation A review of the manufacturer's recommendation for Assure Platinum a professional blood glucose monitoring system provided by the director of nursing (DON) on 3/6/24 at 3:36 p.m. recommended a control solution test be performed: -Before testing with the Assure Platinum System for the first time; -When new bottles of test trips were opened; -Whenever you suspect the meter or test strips may not be functioning properly; -If test results appear to be abnormally…

    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 · E2023-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide a clean, comfortable, homelike environment for residents. Specifically, the facility failed to ensure: -Resident rooms and unit hallways were clean, comfortable, free of urine odors and in good repair throughout the facility; and -Resident bed linens were in clean, stain-free condition. Findings include: I. Facility policy The Homelike Environment policy, revised February 2021, provided by the nursing home administrator (NHA) on 8/28/23, included in pertinent part: Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes to the extent possible the characteristics of the facility that reflect a personalized, homelike setting to include: -clean, sanitary and orderly environment; -clean bed and bath linens that are in good condition; -pleasant, neutral scents. II. Observations and interviews On 8/23/23 starting at 8:45…

    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 · Ecited before2023-08-29 · 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, record reviews, and interviews, the facility failed to ensure that drugs/biologicals were stored and disposed properly upon expiration. Specifically, the facility failed to dispose of expired Cephalexin (antibiotic medication) and Levemir injection pen (insulin medication device). Findings include: I. Professional reference According to the Food and Drug Administration (FDA), FDA, Keflex (Cephalexin) Oral Suspension, Highlights of Prescribing Information (2018), retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/050406s013lbl.pdf, on 9/5/23, advised refrigerate Cephalexin after mixing. Medication may be kept for 14 days without significant loss of potency. According to Novo Nordisk, manufacturer recommendations, Taking Levemir (2022), retrieved from https://www.mynovoinsulin.com/insulin-products/levemir/taking-levemir.html, on 9/5/23, Dispose of the Levemir pen after 42 days, even if there is insulin left in the pen. II. Facility policy The facility medication labeling and storage policy, revised February 2023, was provided by the 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 observation, interviews and record review the facility failed to store food in a sanitary manner in one of two residents' snack refrigerators. Specifically, the facility failed to ensure proper unit refrigerator temperatures were maintained in the south hall for resident snack refrigerators that contained ready to eat perishable foods intended for resident consumption. Findings include: I. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 9/5/23 from https://cdphe.colorado.gov/environment/food-regulations read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified. The FDA (Food and Drug Administration) food code reviewed 3/27/23 and retrieved 9/5/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 read in pertinent part, Bacterial growth and/or toxin…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interview, the facility failed to ensure immediate notification to the resident's representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for one (#120) resident reviewed out of 33 sample residents. Specifically, the facility failed to make timely notification of Resident #120's change of condition to the resident's legal representative. Findings include: I. Facility policy The facility Change in a Resident's Condition or Status policy revised February 2021 was provided by the nursing home administrator on 8/29/23 at 5:30 p.m. It read in pertinent part: Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medial/mental condition and or status. A 'significant change' of condition is a major decline or improvement in the resident's…

    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 · D2023-08-29 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 a written notice of bed hold was provided at the time of hospitalization to two (#121 and #122) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to ensure Resident #121 and Resident #122 and their representative(s) were provided a bed hold notice informing them of their right for timely readmission after a therapeutic leave and appeal procedures for denial of readmission when sent to the hospital for mental health treatment. Findings include: I. Facility policy and procedure The Bed Hold policy and procedure, undated, was provided by the nursing home administrator (NHA) on 8/29/23 at 5:30 p.m. It revealed, in pertinent part, Residents and or representative are informed of the facility and state bed hold policy. All residents/representatives are provided written information regarding the facility bed-hold policies, which addresses holding or reserving a resident's bed during periods of absence…

    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 · D2023-08-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide services by qualified persons for one (#64) out of 35 sample residents. Specifically, the facility failed to ensure Resident #64 was assessed by a registered nurse (RN) after a fall. Findings include: I. Resident status Resident #64, under age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included anxiety disorder, depression, presence of right artificial hip joint, osteoporosis, chronic obstructive pulmonary disease (COPD), fracture of an unspecified part of the neck, pain in the right leg, unsteadiness on feet, repeated falls, and acute respiratory failure with hypoxia (insufficient oxygen in the tissue to sustain bodily function) According to the 6/30/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required limited assistance for activities of daily living,…

    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 · Dcited before2023-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure resident were free from accidents and hazards situations for one (#25) of three residents reviewed out of 35 sample residents. Specifically, the facility failed to ensure: -Resident #25 had the ability to access the call light to call for staff assistance during showering; and, -Staff responded to resident #25 when the resident had been in the shower room for over 45 minutes coughing and unable to get to the call light for staff assistance. Findings include: I. Facility policies and procedures The safety and supervision of residents policy, revised 7/2017, was provided on 8/29/23 at 5:30 p.m. by the nursing home administrator (NHA). It read in pertinent part: The facility strives to make the environment as free from accident hazards as possible. The residents' safety supervision and assistance to prevent accidents are the facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through 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 · D2023-08-29 · 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 resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for one (#46) of one resident reviewed for supplemental oxygen use out of 35 sample residents. Specifically, the facility failed to acquire a physician's order before administering oxygen to Resident #46. Findings include: I. Facility policy The Oxygen Administration policy, dated April 14, 2023, was provided on 8/29/23 at 5:30 p.m. by the nursing home administrator (NHA). It read in pertinent part: Oxygen is administered and stored to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plan, and the resident's goals and preferences. The policy explanation and guidelines included: 1. Oxygen will be administered under orders of a physician, except in case of emergency. In such cases, Oxygen shall be administered and orders for Oxygen shall be obtained as soon as practicable when the situation is under…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure drugs and biologicals were stored in locked carts when unattended for 1 of 4 medication carts and 2 of 3 treatment carts. Findings included: A review of facility policy titled, Medication Storage in the Facility, dated 2022, revealed 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During an observation on 06/20/2022 at 11:04 AM, an unlocked medication cart was located in front of the North Hall nurse's desk. Certified Nursing Assistant (CNA) #1 was sitting at the desk, with her back towards the cart. There was one resident sitting in a wheelchair, approximately 10 feet from the unlocked cart. The Assistant Director of Nursing (ADON) walked by the cart twice and did not lock the cart. Resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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, interviews, record reviews, and facility policy review, it was determined the facility failed to accommodate and individualize the physical environment of the resident's bathroom for 1 of 1 resident (Resident #59) reviewed for accommodation of needs. Specifically, the facility failed to provide adequate space in the resident's bathroom to allow the resident to safely transfer themself from a wheelchair to the commode. Findings included: A review of the facility's policy titled, Accommodation of Needs, implemented on 10/01/2021, revealed, 1. The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility .3. Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment. 4. Based on individual needs and preferences, the facility will assist the resident in maintaining and/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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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, record review, and review of facility policy, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 (Resident #28) of 1 resident reviewed for PASARR. Findings included: A review of the facility's policy titled, Resident Assessment Policy and Procedure, dated 2020, revealed, XI. Preadmission screening for individuals with a mental disorder and individuals with intellectual disability. A. The Facility shall not admit any new resident with: a. Mental disorder (an individual is considered to have a mental disorder if the individual has a serious mental disorder as defined in 42 CFR § 483.102 (b) (1), unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission: i. That, because of the physical and mental condition of the individual requires the level of services provided by a nursing facility; and ii. If…

    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 · D2022-06-23 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 1 (Resident #53) of 1 resident observed during medication administration via percutaneous endoscopic gastrostomy (PEG) tube. Specifically, the facility failed to ensure medications, enteral formula, and water were allowed to flow into the PEG tube via gravity, rather than being pushed into the tube with a syringe. Findings included: A review of the facility's policy titled, Enteral Tube Medication Administration, 2022 Edition, revealed the procedure to administer medications included, 8. Flush the tube with 30 ml [milliliters of water. 9. Administer liquid medications first, then those that need to be diluted. Reserve thick medications e.g. [for example] antacids for last. 10. Allow medication to flow down tube via gravity. Review of an admission Record revealed Resident #53 had diagnoses of multiple sclerosis, acute…

    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 · D2022-06-23 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents (Residents #53 and #54) observed during medication administration. Four errors in medications were observed during 28 opportunities for errors in medication administration. This resulted in a medication error rate of 14.28%. Findings included: A review of the facility's policy titled, Medication Administration and General Guidelines, 2022 Edition, indicated the procedure included, 2. Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate .16.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$845 in federal fines across 1 penalty.

  • $845 — penalty dated 2025-10-02

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 LONG PEAK OPERATING COMPANY — 8 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 →

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 3 of 52.9+0.1 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 7 homes this chain runs (chain average 2.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
CRESTMOOR SNF HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2024
LONG PEAK OPCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2024
MOSKOWITZ, JAYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2024
RASKIN, CHAIMIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 03/01/2024
VALLE, KARLAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 09/01/2024
HASKELL, CYNTHIAIndividualCORPORATE OFFICER; ADP OF THE SNFsince 09/01/2024
BEECAN HEALTH CO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2024
STERN, AKIVAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2024
DERGANCE, JEANNAEIndividualADP OF THE SNFsince 09/01/2024
KORETKE, MARYIndividualADP OF THE SNFsince 09/01/2024

CMS files one row per role, so the 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$8.0M
Net patient revenuemost recent cost report
-5.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 90%Medicare 5%Other / private 5%

About 90% 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. 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

$331per resident / day
operating cost
$10,055per month
≈ monthly operating cost
$314per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Colorado
$10,159/mo
Nursing home (semi-private)
$12,182/mo
Nursing home (private)
$6,584/mo
Assisted living

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 065290. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-06, 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.

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