Castle Peak Senior Life And Rehabilitation

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 69.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 44 beds and averages 40.1 residents a day — about 91% occupied, or roughly 4 beds typically open. It runs fairly full. 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 5.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.14 is at or above 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 4.30 hrs/resident/day on weekends vs 5.31 on weekdays — 19% thinner on weekends. RN hours go from 1.82 to 1.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

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

Inspection trend

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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

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

• Actual harm · Gcited before2026-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and observations, the facility failed to ensure residents were free from accidents or hazards for one (#1) of four residents reviewed for accidents hazards out of seven sample residents. Specifically, the facility failed to ensure Resident #1 was provided a hot beverage without injury. Resident #1, was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified cataract, unspecified macular degeneration (loss in central vision of the eyes), disorientation, unspecified, and restlessness and agitation. On 11/12/25 Resident #1 was provided a hot beverage dispensed from the facility's coffee machine and then heated in the microwave for an additional 30 seconds, per the resident's request, by a staff member. Resident #1 was visually impaired and could not find the opening on the lid to drink the hot beverage. The resident attempted to remove the lid, causing the beverage to spill…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-09-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#10 and #35) of five residents out of 23 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #10 was admitted to the facility for long-term care on 4/6/18 with diagnoses of dementia, stroke, and seizure disorder. Upon admission, the resident weighed 117 pounds (lbs). On 7/30/24, Resident #10 weighed 145.6 lbs. On 9/3/24 the resident weighed 126 lbs. Resident #10 sustained a 18.6 lbs (12.8%) weight loss from 7/30/24 to 8/27/24 in one month, which was considered severe weight loss. Due to the facility's failure to accurately assess and implement nutrition interventions timely the resident's weight continued to decline. Additionally, Resident #35 admitted on [DATE] with a diagnosis of gastroesophageal reflux disease (GERD), arthritis and thyroid disorder. Upon admission, the resident weighed 107 lbs. On 8/1/24 the facility…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-12-02 · 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 record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for one (#9) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility failed to ensure Resident #9 was free from physical abuse from a staff member. Resident #9 was dependent on staff for care and cognitively impaired. Resident #9 was struck in the eye when a staff member threw chocolate at her. The action resulted in a hematoma (bruising) to her right eyelid and was given ice and Tylenol for the pain (see the nurse practitioner's note). The resident reported feeling fearful and per certified nurse aide #8 statement the resident was crying after the incident. Findings include: I. Facility policy and procedure The Abuse Prohibition-Occurrence Reporting policy, last reviewed 10/5/21, was provided by the facility on 11/30/21. The policy read in part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-12-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by significant weight loss for one (#20) of two residents reviewed for nutrition status services of 20 sample residents. Specifically, the facility failed to ensure Resident #20 had interventions in place to prevent significant weight loss. Resident #20 experienced significant weight loss of 11.34% within a two month time frame, which was considered significant weight loss. The registered dietitian (RD) had a history with the resident as she had been previously admitted in April 2021, where she experienced a 10 lb (pound) weight loss in seven months. The facility waited until Resident #20 experienced significant weight loss this admission before implementing interventions such as Ensure shake, eating in dining room, and cuing assistance during meals to prevent weight loss. Staff did 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2021-12-02 · tag F0742 — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to ensure a resident with mental and psychosocial adjustment, received appropriate treatment to attain the highest practicable mental and psychosocial well-being for one (#26) of two residents reviewed for mood and behavior out of 20 sample residents. Resident #26 expressed a preference not to have male caregivers providing activites of daily living (ADL) care. A request of the Resident #26's preference not to have male caregivers was documented on 7/31/21. Resident #26 required two assistance for most of her ADLs. Two CNAs for both the day and night were scheduled on the unit where the resident resided. The review of the schedule between August 2021 and 11/30/21 identified at least one male staff member, on at least one shift, was scheduled to work with the resident on almost a daily basis. The resident had a history of hallucinations and a diagnosis of dementia with behavioral disturbances. Between 7/11/21 and 11/30/21, the resident had…

  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 · D2026-03-10 · 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 record review and interviews, the facility failed to provide reasonable accommodations for one (#2) of three residents out of seven sample residents.Specifically, the facility failed to provide timely accommodations for moving Resident #2's personal belongings during a room change. Findings include:I. Facility policy and procedureThe Room Change policy, revised April 2025, was provided by the nursing home administrator (NHA) on 3/10/26 at 7:18 p.m. The policy read in pertinent part, A resident may request a room transfer at any time. The resident's request for transfer will be honored if there is an available bed on an appropriate unit and if the resident is able to comply financially with any potential private room differential. Environmental services staff or designee will assist the resident to pack their belongings prior to the room change. A nursing assistant or designee will bring the resident to the new room at the time of the room change and will introduce the resident to any new staff, as…

  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 before2026-03-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#2) of three residents out of seven sample residents.Specifically, the facility failed to report an allegation of verbal abuse towards Resident #2 by the director of nursing (DON) to the State Agency.Findings include:I. Facility policy and procedureThe Occurrence Reporting-Vulnerable Adult policy, revised October 2022, was provided by the nursing home administrator (NHA) on 3/10/26 at 6:09 p.m. The policy read in pertinent part, Report all alleged violations and substantiated incidents immediately, but no later than 2 (two) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury to 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-10 · 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 thoroughly investigate allegations of abuse for one (#2) of three residents out of seven sample residents.Specifically, the facility failed to maintain documentation to indicate a thorough investigation was completed after an allegation of verbal abuse towards Resident #2 by the director of nursing (DON).Findings include:I. Facility policy and procedureThe Occurrence Reporting-Vulnerable Adult policy, revised October 2022, was provided by the nursing home administrator (NHA) on 3/10/26 at 6:09 p.m. The policy read in pertinent part, All reports of suspected/alleged resident abuse, neglect, exploitation of residents, mistreatment, injury of unknown source and/or misappropriation of resident property shall be promptly and thoroughly investigated. All interviews related to the investigation shall be conducted in private. The investigation may include, but is not limited to: physical examination of the resident and environment; examination of the resident…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  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 (#1) of three residents was provided the care and services necessary to ensure a safe discharge from the facility to the community out of three sample residents.Specifically, the facility failed to:-Allow Resident #1 to return to the facility after an unplanned discharge to the hospital;-Provide documentation from Resident #1's physician, including the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and,-Reassess Resident #1 for readmission after he was stabilized at the hospital and ready to return to the facility. Findings include:I. Facility policy and procedureThe Discharge Notice Requirements policy and procedure, revised 4/28/25, was provided by the director of nursing (DON) on 8/20/25 at 1:40 p.m. It read in pertinent part, The facility must…

  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 · D2025-06-18 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints for one (#1) of three residents out of five sample residents. Specifically the facility failed to: -Ensure Resident #1 had physician's orders for the placement of a wanderguard; and, -Obtain consent to move Resident #1 to the secured unit, which prevented the resident from activities that met his interests. Findings include: I. Facility policy and procedure The Physical Restraint policy, revised 10/14/22, was provided by the director of nursing (DON) on 6/16/25 at 4:05 p.m. The policy read in pertinent part, Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the residence body that the individual cannot remove easily and which restrict freedom of movement or normal access to one's body. It is the policy of the facility to use restraints only under the following conditions; as a last resort after a trial period where…

  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 · Dcited before2024-09-19 · 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 record review and staff interviews, the facility failed to ensure one (#23) of three residents reviewed for abuse out of 23 sample residents was kept free from abuse. Specifically, the facility failed to: -Prevent Resident #22 from slapping Resident #23; -Thoroughly investigate a resident to resident altercation between Resident #22 and Resident #23; and, -Put interventions in place to prevent future resident to resident altercations between Resident #22 and Resident #23. Findings include: I. Facility policy and procedure The Vulnerable Adult policy, reviewed 10/20/23, was provided by the nursing home administrator (NHA) at 10:15 a.m. The policy documented in pertinent part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. This includes but is not limited to freedom from corporal punishment, and voluntary seclusion in any other physical or chemical restraint not required to…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-09-19 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 (#145) of 23 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #145's vital signs were taken after the resident sustained an unwitnessed fall in her room. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1780, retrieved on 9/23/24, : In the event of a fall, perform a post-fall assessment to identify possible causes. Monitor patients closely for 48 hours after a fall. IV. Resident #145 A. Resident status Resident #145, under the age of 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), renal insufficiency, and chronic obstructive pulmonary disease (COPD). The 9/18/24 minimum data set (MDS) assessment revealed the resident was…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  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 (#14 and #37) of five residents reviewed were free from unnecessary psychotropic medications out of 23 sample residents. Specifically, the facility failed to ensure as-needed psychotropic medications for Resident #14 and Resident #37 had an identified end date from the prescriber. Findings include: I. Facility policy and procedure The Psychotropic Medication Monitoring policy, reviewed 3/4/24, was received from the nursing home administrator (NHA) on 9/19/24 at 11:09 a.m. It read in pertinent part,Residents who use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. II. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), stroke and respiratory failure. The 8/5/24 minimum…

  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 · D2024-09-19 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one resident (#5) out of five residents reviewed were free from significant medication errors out of 23 sample residents. Specifically, the facility failed to ensure, for Resident #5: -Antibiotics were started as ordered; -The correct antibiotic was given as ordered; -The physician was notified when the antibiotics were not available; and, -Timely identification and notification of a significant medication error. Findings include: I. Facility policy and procedure The Medication Administration policy, last reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:14 p.m. The policy read in pertinent part, Medications will be administered to residents as prescribed by the primary MD (medical doctor)/NP (nurse practitioner)/PA (physician assistant). Staff will follow the six rights of medication administration. Right resident, right medication, right dose, right dosage form, right frequency and right route. Medications…

  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 · Dcited before2023-03-16 · 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 staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#26 and #29) of five residents reviewed for accident hazards out of 19 sample residents. Specifically, the facility failed to: -Conduct a thorough investigation was completed after an unwitnessed fall with injury for Resident #26; -Ensure appropriate and effective preventive fall measures and communication, were in place to prevent recurrence of a fall for Resident #26; and, -Investigate Resident #29's skin conditions and implement preventative measures. Findings include: I. Resident #26 A. Facility policy and procedure The Fall Assessment and Managing Fall Risk policy, last reviewed 10/17/22, was provided by the facility on 3/16/23. The policy identified procedures the facility should incorporate to manage the risk for falls. According to the policy, the facility should initiate appropriate interventions to minimize risk of falls and/or risk…

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

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

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

Fines & penalties

$23,580 in federal fines across 2 penalties.

• $14,015 — penalty dated 2026-03-10
• $9,565 — penalty dated 2025-08-20

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 CASSIA — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 33 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

This home reported $616K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CO