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Health Center At Franklin Park

1535 Park Ave, Denver, CO 80218 · Non profit - Corporation · 86 certified beds · (303) 479-3692 Medicare & Medicaid certified

Call the home — (303) 479-3692 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 20242 actual-harm citations$10,082 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,082 in federal fines (most recent 2023-08-31)
  • its payroll-based staffing score sits well above its independent inspection score

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1625 Marion St · (303) 830-7337 · Call to confirm hours
Pharmacy
1245 E Colfax Ave Ste 102 · (877) 470-7603 · Call to confirm hours
Grocery
770 E 17th Ave · (303) 894-9499 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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 rating4★
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 increased25.3%13.4%15.4%worse
Long-stay residents who lose too much weight1.6%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 infection1.9%1.4%2.0%typical
Long-stay residents with depressive symptoms3.0%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 injury2.8%3.4%3.3%better
Long-stay residents whose ability to walk worsened15.0%13.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication12.0%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.7%95.3%typical
Long-stay residents with pressure ulcers1.0%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control22.5%21.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table21.3%20.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication10.7%1.6%1.4%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.

Staffing

0.76
RN hours/ resident / day
1.02
LPN hours/ resident / day
2.23
Aide hours/ resident / day
4.02
Total nurse hours/ resident / day
0.52
RN hoursweekends
33.9%
Total nursing turnover
38.5%
RN turnover

How full it usually is: this home is certified for 86 beds and averages 60.3 residents a day — about 70% occupied, or roughly 26 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.67 hrs/resident/day on weekends vs 4.16 on weekdays — 12% thinner on weekends. RN hours go from 0.86 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-03-26)
7
at the previous standard inspection (2024-02-27)

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.

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.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2022-11-03 · 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 C. Resident #15 1. Resident status Resident #45, under age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses include chronic obstructive pulmonary disease (COPD), history of falling, generalized anxiety disorder, cerebral infarction (stroke), unsteadiness on feet, muscle weakness, and difficulty walking. The 9/9/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental health status score of 11 out of 15. According to the MDS assessment the resident required extensive assistance from two people with bed mobility, transfers, toileting and one person assistance with walking in the room, corridor, on and off the unit, personal hygiene, and dressing. The resident was unsteady while moving from seated to standing position, surface to surface transfers, walking, turning around, and moving on and off the toilet. The resident has a manual wheelchair that requires substantial to maximum…

    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 · G2022-11-03 · 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, staff interviews, and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#60 and #62) of two residents reviewed for catheter care, out of 31 sample residents. Resident #60 admitted to the facility on [DATE] without having a catheter in place. The resident did not have a medical diagnosis to provide clinical indication (reason) for the need for a catheter. While in the care of the facility, the resident fell and fractured a hip and required surgical intervention. The resident returned to the facility on 9/1/22 with the indwelling catheter. The facility failed to ensure Resident #60 had orders for the use of an indwelling catheter to assist the resident with bladder function. The facility failed to conduct a comprehensive assessment to determine if the indwelling catheter was clinically indicated. The facility failed to have order for routine catheter care to maintain a healthy bladder 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 · E2026-03-26 · tag F0679 — failed to provide activities — pattern
    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, interviews and record review, the facility failed to provide activities designed to support residents' physical, mental and psychosocial well-being were provided for one (#10) of four residents reviewed for meaningful activity programming activities out of 32 sample residents and on one of three units.Specifically, the facility failed to:-Offer and provide a personalized activity program for Resident #10;-Ensure Resident #10 was invited and encouraged to attend activities of the resident's preference; and,-Ensure a meaningful activities program was consistently provided to residents residing in the facility's secured dementia care unit.Findings include: I. Facility policy and procedure The Activities policy, revised 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It revealed in pertinent part, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    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 the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.Findings include: I. Professional referenceAccording to the National Certification Council of Activity Professionals (NCCAP) (2023), retrieved on 3/31/26 from www.nccap.org, an activity director must meet specific qualifications in education, certification and/or experience,The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the state in which practicing; and,-Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or,-Has two (2) years of experience in a social or recreational program within the last 5 (five) years, one of which was full-time in 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 · E2026-03-26 · 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 all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of three medication carts.Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. Facility policy and procedureThe Medication Storage policy, dated 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.II. ObservationsOn 3/26/26 at 8:30 a.m. medication cart #2 on the second floor was observed with registered nurse (RN) #1. The following items were found:There was one umeclidinium-bromide (Incruse…

    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 · E2026-03-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for three of five emergency (crash) carts.Specifically, the facility failed to:-Ensure staff completed daily equipment checks;-Ensure expired items were removed from the crash cart;-Ensure missing items were replaced on the crash cart; and,-Ensure staff had knowledge of which electrical outlets were connected to the emergency backup generator. Findings include:I. Professional referenceAccording to [NAME], [NAME], May 2022, retrieved on 3/30/26 from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review,A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency.A crash cart is typically located in the setting of an unexpected…

    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 · D2026-03-26 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#28 and #55) of five residents were free from chemical restraints out of 32 sample residents.Specifically, the facility failed to: -Ensure Resident #28's representative was informed of the facility's decision to implement a gradual dose reduction (GDR) after the pharmacist and the physician recommended a GDR of the resident's Zyprexa (antipsychotic medication);-Ensure Resident #55's antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary team (IDT); and, -Ensure Resident #55's care plan included resident-specific non-pharamacological care approaches for the resident's behaviors.Findings include: I. Facility policy and procedure The Gradual Dose Reduction (GDR) of Psychotropic Drugs policy, revised on [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 11:47 a.m. It read in pertinent part, Residents who use psychotropic drugs receive gradual dose reductions and behavioral…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · 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 received services and assistance to prevent a reduction in range of motion for two (#6 and #10) of four residents reviewed for range of motion out of 32 sample residents. Specifically, the facility failed to: -Ensure preventative measures were put into place for Resident #6's bilateral hand contractures; and, -Ensure preventative measures were followed for Resident #10 to prevent further body misalignment.Findings include: I. Facility policy and procedure The Restorative Care policy and procedure, revised 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It read in pertinent part, Residents will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services include passive or active range of motion, splint or brace assistance, and bed mobility training and skill practice. Potential candidates for restorative nursing services may 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 · Ecited before2024-02-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in two of three units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure resident glucometers were cleaned in a sanitary manner; and, -Ensure gloves were worn while administering an insulin injection. Findings include: I. Failure to clean rooms in a sanitary manner and follow disinfectant surface contact times A. Professional reference According to The Centers for Disease Control (CDC) Environment Cleaning Procedures (5/4/23), retrieved on 2/29/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118, Proceed from cleaner to dirtier areas to avoid spreading dirt 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · 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 observation, interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#30) of three residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to protect Resident #165 from physical abuse from Resident #30. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 10/30/23, was provided by the nursing home administrator (NHA) on 2/22/24 at 8:37 a.m. The policy revealed in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting and intervening 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#21) of three residents out of 23 sample residents investigated for abuse. Specifically, the facility failed to report two allegations of verbal abuse of unidentified residents by Resident #21 to local law enforcement and the State Agency on 9/21/23 and 1/7/24. Cross reference F610 for failure to investigate an alleged violation Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 10/30/23, was provided by the nursing home administrator (NHA) on 2/22/24 at 8:37 a.m. The policy revealed in pertinent part, Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or other but has not yet been investigated and, if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source…

    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 · D2024-02-27 · 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 an allegation of abuse for one (#21) of three residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to ensure two incidents of verbal abuse of unidentified residents by Resident #21 on 9/21/23 and 1/7/24 were thoroughly investigated and documented in a timely manner. Cross-reference F609 for failure to report an alleged violation. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 10/30/23, was provided by the nursing home administrator (NHA) on 2/22/24 at 8:37 a.m. The policy revealed in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not…

    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 15 citations
  • Potential for harm · D2024-02-27 · 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 one (#24) of three residents reviewed for pressure ulcers out of 23 sample residents received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure Resident #24 did not experience a worsening of a shear/friction injury, which the resident was readmitted to the facility with, to an unstageable pressure injury. 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 Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/28/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early…

    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 before2024-02-27 · 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

    Based on observations, record review and interviews, the facility failed to ensure the environment remained as free of accident hazards as is possible, and ensure each resident received adequate supervision for six residents who resided on the secure unit out of 23 sample residents. Specifically, the facility failed to ensure Resident #59's private sitter, who was hired by the resident's family, did not provide assistance to other residents who resided on the secure unit. Findings include: I. Observations and interviews The private sitter (PS) #1 was interviewed on 2/21/24 at 11:25 a.m. PS #1 said he did not work at the facility and was a private sitter for a resident. PS #1 said Resident #59's family asked him to be a private sitter for Resident #59. On 2/21/24 At 11:50 a.m., PS #1 was observed during mealtime in the secured unit. An unidentified resident was seated and a lunch plate was set on the table in front of her. The resident had not taken a bite of her food. PS #1 was observed lifting the unidentified resident's fork with food to her mouth to attempt to offer her food. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 observations, record reviews and interviews, the facility failed to ensure two (#60 and #24) of three residents reviewed for unnecessary medications out of 23 sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to: -Ensure Resident #60 and Resident #24 were adequately monitored and documented side effects of anticoagulant medication; and, -Establish pain parameters for pain medications for Resident #24. Findings include: I. Professional reference According to Vallerand and Sanoski, 2021 [NAME]'s Drug Guide for Nurses, seventeenth edition, page 176, Apixaban (Eliquis), classification therapeutic: anticoagulants. Assessment: Assess patient for symptoms of stroke, DVT (deep vein thrombosis), PE (pulmonary embolism), bleeding, or peripheral vascular disease periodically during therapy. Patient teaching: Inform patient that they may bruise and bleed more easily or longer than usual. Advise patient to notify health care professional immediately if signs of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-31 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    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 establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program. Specifically, the facility failed to have a process in place to track antibiotic usage in the facility. Findings include: I. Professional standard The Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on [DATE], included the following recommendations: Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community…

    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 · F2023-08-31 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all 64 residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program. Findings include: I. Professional references The Centers for Disease Control and Prevention (CDC) (updated 3/29/21) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, retrieved on 9/7/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Assign One or More Individuals with Training in Infection Control to Provide On-Site Management of the IPC Program. This should be a full-time role for at least one person in facilities that have more than 100 residents.…

    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 · F2023-08-31 · tag F0883 — failed to offer flu and pneumonia vaccines — widespread
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for 15 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 15 residents reviewed for immunizations out of 18 sample residents. Specifically, the facility failed to: -Offer Resident #1 the pneumococcal vaccine upon admission; -Failed to determine which pneumococcal vaccine was given to Resident #3, Resident #4 and Resident #15 and offer additional doses as needed; -Ensure Resident #5 and Resident #7 ' s electronic medical record (EMR) was up to date; -Administer and document Resident #6, Resident #9, Resident #10, Resident #12 and Resident #13 received the pneumococcal vaccine after consenting; and, -Offer additional doses of the the pneumococcal vaccine to Resident #8. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United…

    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 · Ecited before2023-08-31 · 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

    Based on observations, record review and interviews, the facility failed to ensure three of three units were free from accident hazards. Specifically, the facility failed to: -Ensure three of three serving kitchens were equipped with ventilation hoods when cooking items that contained grease -Ensure coffee was served at an appropriate temperature on the first floor unit; and, -Ensure linens, chemicals and dry storage was stored appropriately. Findings include: I. Failed to have ventilation hoods when cooking items that contained grease A. Facility policy and procedure The Fire Prevention policy, dated 2021, was provided by the admissions coordinator (AC) on 8/31/23 at 6:55 p.m. It revealed in pertinent part, The facility should be constructed, equipped and maintained to promote fire safety and protect the health and safety of patients/residents, employees and the public. Hoods, fans, vents, grills, and other equipment should be kept free of grease and dust accumulation. B. Observations The facility had three floors. Each of the floors had a kitchenette, which contained a sink,…

    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 · E2023-08-31 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for four of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #4 and CNA #5. Findings include: I. Record review A request for CNA #2 (hired 3/9/2020) , CNA #3 (hired 6/17/03) and CNA #4 (hired 1/29/22), and CNA #5 (hired 9/10/23) annual performance review and in-service education based on the outcome of the reviews on 8/31/23. The staff development coordinator provided a copy of CNA #2's last performance review that had been completed on 8/22/22. CNA #3, CNA #4, CNA #5 and CNA #6 did not have a performance review. CNA #2, CNA #4 and CNA #5 had not completed the annual in-service education based on the outcome of their reviews. II. Staff interviews The staff development coordinator (SDC) 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-31 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease in three of three units. Specifically, the facility failed to: -Ensure hand hygiene was offered to residents before meals on the first and second floors; -Ensure hand hygiene was performed after providing incontinence care; and -Ensure laundry was sorted and cleaned properly; Findings include: I. Failure to provide hand hygiene opportunities for residents A. Facility policy and procedure The Handwashing/Hand Hygiene policy, dated September 2019, was provided by the assistance director of nursing (ADON) on 8/31/23 at 6:15 p.m. It revealed in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. B. Observations During a continuous observation in the first floor dining room on 8/30/23 beginning at 11:20 a.m. and ended at 12:14 p.m. the following showed: -At 11:25 a.m. there were…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-03 · 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 observation, document review, and interviews the facility failed to provide a clean, safe, homelike environment for residents on two of three units and in resident common areas. Specifically the facility failed to : -Ensure the privacy curtains were changed on a regular basis; -Ensure the facility was free from urine odors; -Provide clean floors in resident rooms and throughout the facility; -Ensure resident rooms and furnishings were clean, neat, and tidy; -Ensure the heating units in resident rooms were clean and free form dust build up; -Ensure trash cans in resident rooms that contained soiled adult incontinence briefs were emptied timely; -Ensure resident shared medical equipment was in clean condition; -Ensure the shower rooms were cleaned after each use and maintained in good repair free from odors; -Ensure the resident showers were in good repair with safe flooring and functional faucets with easy to control water temperatures; and, -Ensure that facility vents in resident bathrooms; common…

    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 · E2022-11-03 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 certified nurse aides (CNAs) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure CNA staff had completed competencies prior to providing resident care for four (#3, #4, #5 and #6) out of five CNAs reviewed for competencies. Findings include: I. Facility policy The Competency of Nursing Staff policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 11/3/22 at 8:30 p.m. It read, in pertinent part, All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements. Licensed nurses and nursing assistants employed by the facility will participate in a facility specific, competency-based staff development and training program and will demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents. Facility 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-03 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases for two out of three units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned all high-touch surfaces in resident rooms and followed manufacturer surface contact time during routine daily cleaning; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident rooms and bathrooms; -Ensure houskeeping staff implemented appropriate hand hygiene with glove changes when moving form handling soiled linens and trash to providing resident care and services; and, -Ensure residents were offered hand hygiene prior to eating meals. Cross referenced to F584 failure to maintain a clean sanitary homelike environment. Findings include: I. Housekeeping services A. Professional standards The Centers for Disease Control 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-03 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to inform residents of changes in their services covered by Medicare as required, for two (#18 and #23) of three who remained in the facility once services ended, out of 31 sample residents. Specifically, the facility failed to ensure the residents were fully informed of their rights regarding facility initiated discharges from Medicare part A services. The facility failed to: -Ensure Resident #18 and #23 were fully informed and provided a full description of the type of Medicare part A services that were ending, give the estimated cost of services should the resident choose to pay out of pocket to continue services, and the reason why Medicare would not continue to pay for the particular service, should the resident decided to appeal the direction; and -Ensure Resident #23 was given timely information about termination of Medicare part A service within the required 48 hours notification timeframe, in order to give the resident the opportunity to appeal the decision if desired. Findings include: 1. Practice standards…

    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 · D2022-11-03 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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, resident and staff interviews, the facility failed to maintain privacy for one (#62) one of two residents reviewed for privacy out of 31 sample residents. Specifically, the facility failed to ensure Resident #62 received privacy during personal care. Findings include: A. Resident status Resident #62 , under the age of 65, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO) diagnoses included schizoaffective disorder, bipolar type, pressure ulcer stage 4, dementia, insulin dependent diabetes mellitus. According to the 9/9/22 minimum data set assessment (MDS) the resident had severely impaired cognition as evidenced by a score of five out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with personal hygiene. B. Observation On 11/1/22 at 10:30 a.m., the resident was assisted in order for a wound dressing to be changed. Licensed practical nurse (LPN) #3 positioned the resident on her bed, laying on 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-03 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 record review and staff interviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program for two (#15 and #43) of two residents reviewed for PASRR compliance out of 31 sample residents. Specifically the facility failed to include PASRR level II in the resident's medical record for Resident #15 and PASRR Level I or II for resident #43. Findings include: I. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE]. The November 2022 computerized physicians order (CPO), indicated a diagnosis of personal history of transient ischemic attack (stroke), post-traumatic stress disorder (PTSD), contracture of left hand, alcohol abuse and palliative care. The 9/13/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status (BIMS) of 14 out of 15. He required maximal assistance with bathing, toileting, dressing and bed mobility. B. Record review The clinical care plan,…

    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

“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

$10,082 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $10,082 — penalty dated 2023-08-31
  • Medicare payment denial — starting 2023-09-29 for 24 days

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

Part of a chain

This home belongs to AMERICAN BAPTIST HOMES OF THE MIDWEST — 6 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 4 of 52.3+1.7 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 5 of 53.8+1.2 vs chain
Quality measures 3 of 53.3-0.3 vs chain
The other 5 homes this chain runs (chain average 2.3★, 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
BAPTIST HOME ASSOCIATION OF THE ROCKY MOUNTAIN INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2000
KOTZ, CHRISTINAIndividualW-2 MANAGING EMPLOYEEsince 01/01/2020
ALLEN, RYANIndividualCORPORATE DIRECTORsince 01/01/2013
DAVIDSON, ROGERIndividualCORPORATE DIRECTORsince 01/01/2020
FORD, ASHLEYIndividualCORPORATE DIRECTORsince 01/01/2020
HANSON, PHILLIPIndividualCORPORATE DIRECTORsince 01/01/2013
JOHNSON, DOROTHYIndividualCORPORATE DIRECTORsince 01/01/2020
JOHNSON, JAMESIndividualCORPORATE DIRECTORsince 01/01/2020
KILLIAN, GEORGEIndividualCORPORATE DIRECTORsince 01/01/2020
NEIMAN, RUTHIndividualCORPORATE DIRECTORsince 01/01/2020
PETERS, MARSHALLIndividualCORPORATE DIRECTORsince 01/01/2013
VAN DER BEEK, BRUCEIndividualCORPORATE DIRECTORsince 01/01/2020
VANOSTRAM, STEVENIndividualCORPORATE DIRECTORsince 01/01/2013
VAUGHN-GRAY, STEPHANIEIndividualCORPORATE DIRECTORsince 01/01/2020
WAGONER FORD, ANNEIndividualCORPORATE DIRECTORsince 01/01/2020
WHITAKER, BRUCEIndividualCORPORATE DIRECTORsince 01/01/2013
BLATNIK, ANDREAIndividualCORPORATE OFFICERsince 01/01/2020
JOHNSON, LARSIndividualCORPORATE OFFICERsince 06/05/2023

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.

$8.1M
Net patient revenuemost recent cost report
-6.0%
Operating marginrevenue minus expenses
$385K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 7%Other / private 21%

About 72% 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 $385K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 2024. 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

$417per resident / day
operating cost
$12,689per month
≈ monthly operating cost
$394per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 065213. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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