Horizons Care Center
11411 Highway 65, Eckert, CO 81418 · Non profit - Corporation · 45 certified beds · (970) 835-2600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2022
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,180 in federal fines (most recent 2023-09-05)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.3% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 4.7% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.9% | 1.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.6% | 8.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.6% | 13.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.6% | 11.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.2% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.5% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.9% | 20.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 59.7% | 75.6% | 79.4% | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.9%CMS range 48.2–65.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.3–16.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.2–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 45 beds and averages 31.1 residents a day — about 69% occupied, or roughly 14 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.05 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 3.32 hrs/resident/day on weekends vs 4.23 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.24 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% 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.
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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2023-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#1) of three residents reviewed for falls out of three sample residents. Specifically, the facility failed to ensure Resident #1, who was at high risk for falls, had adequate supervision at night. Resident #1 was left alone on 7/7/23 late at night in the living room without a call light available so she could call for help. As a result, Resident #1 sustained a fall on 7/7/23 and had to be airlifted to the hospital for treatment, where she was diagnosed with a subdural hematoma (a collection of blood that forms on the surface of the brain). Findings include: I. Facility policy The Fall Management Program policy, revised 10/24/22, was provided by the health information manager (HIM) on 9/5/23 at 5:38 p.m. and read in pertinent: All residents are assessed to identify risk for falls and individualized fall precautions will be developed in their care plan. Falls Program: 1.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-04-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that the residents environment was free from accident hazards and received supervision and assistance to prevent accidents and hazards for two (#9 and #13) of six sample residents out of 26 sample residents. The facility failed to ensure a hot beverage was a safe temperature before it was served to Resident #9. Due to the facility failures, the resident experienced a burn that caused her pain after a hot beverage spilled onto her right lower leg. In addition, Resident #13 was kept free from an accident in a malfunctioning wheelchair. Findings include: I. Professional reference According to the U.S. Consumer Product Safety Commission (CPSC) regarding Tap Water Scalds. Document #5098, retrieved from https://www.cpsc.gov on 4/19/23. Most adults will suffer third degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six second exposure to 140 degree water or with a thirty second exposure to 130…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-06 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 and investigate allegations of abuse involving three (#2, #3 and #7) of six residents reviewed for abuse out of 11 sample residents.Specifically, the facility failed to timely report potential abuse towards Resident #2, Resident #3 and Resident #7.Findings include:I. Facility policy and procedureThe Resident Protection Freedom from Abuse, Neglect, and Misappropriation policy, revised 11/3/22, was provided by the nursing home administrator (NHA) on 1/5/26 at approximately 6:00 p.m. It read in pertinent part, Each individual has the right to be free from verbal, sexual, physical, and mental abuse, including injuries of unknown source, misappropriation of resident property, corporal punishment, mistreatment, including, but not limited to, facility/service staff, other resident, consultants, volunteers, or other individuals. Employees must always report alleged abuse/neglect immediately to the supervisor or the building supervisor. The executive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-07 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Implement an effective water management plan; -Appropriately discard Resident #8's medication that was dropped; and, -Provide proper infection control practices while maintaining an indwelling catheter. Findings include: I. Failure to have an effective water plan A. Professional reference According to Center for Disease Control (CDC), Legionella (Legionnaires Disease and Pontiac fever), last reviewed 3/25/21, was retrieved on 11/12/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure hand hygiene was conducted appropriately; and, -Santitize potentially contaminated surfaces of a food preparation counter. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/22/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 ensure the self-administration of medications was clinically appropriate for one (#9) of one out of 20 sample residents. Specifically, the facility failed to appropriately assess Resident #9 for self-administration of medications. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 2016, was retrieved on 11/12/24, Do not leave medications at the bedside. If you leave the medication on the bedside table, how do you know they took the medication? Someone else could come in and take or discard the medication. II. Facility policy and procedure The General Dose Preparation and Medication Administration policy, undated, was provided by the nursing home administrator (NHA) on 11/7/24 at 1:47 p.m. It documented in pertinent part, Facility staff should not leave medications or chemicals unattended. III. Resident #9 A. Resident status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 resident choices for one (#18) of five residents reviewed for activities of daily living (ADL) out of 20 sample residents. Specifically, the facility failed to provide bathing assistance for Resident #18 per his preference. Findings include: I. Facility policy and procedure The Showers, Bed Bath and Tub Bath policy, revised March 2012, was received from the corporate consultant (CC) on 11/7/24 at 1:11 p.m. It documented in pertinent part, The facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes ensuring that the facility provides care and services for the following activities of daily living: hygiene - bathing. II. Resident #18 A. Resident status Resident #18, over the age of 65, was admitted on [DATE]. According to the November 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a comfortable homelike environment for residents on one of four units. Specifically, the facility failed to ensure the 400 hallway maintained a temperature of 71 degrees fahrenheit (F) to 81 degrees F. Findings include: I. Facility policy and procedure The Safe Physical Environment policy, revised May 2023, was received from the director of nursing (DON) on 11/7/24 at 1:43 p.m. The policy documented that safe and comfortable temperatures were maintained in the facility. II. Resident interviews One of the residents who resided in room [ROOM NUMBER], who was cognitively intact, was interviewed on 11/4/24 at 3:11 p.m. The resident said his room felt very cold in the morning. He said he had to turn up the thermostat in his room to 78 degrees and close the door to make his room temperature comfortable. The second resident who resided in room [ROOM NUMBER], who was cognitively intact, was interviewed on 11/4/24 at 3:14 p.m. The resident said his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide services by qualified persons for two (#14 and #30) of three residents reviewed for falls out of 20 sample residents. Specifically, the facility failed to ensure Resident #14 and Resident #30 were assessed by a registered nurse (RN) after sustaining unwitnessed falls. Findings include: I. Facility policy and procedure The Fall Management Program policy, undated, was provided by the nursing home administrator (NHA) on 11/7/24 at 3:41 p.m. It documented in pertinent part, All staff are trained on falls. If you are not a nurse and discover a resident has fallen - immediately have someone get a nurse to help assess/collect data while you stay with the resident. II. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included blindness, right and left leg amputations and generalized muscle weakness. The 9/25/24 minimum data set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#11 and#18) of five residents reviewed for activities of daily living (ADLs) received appropriate treatment and services to maintain or improve his or her abilities out of 20 sample residents. Specifically, the facility failed to provide the necessary assistance and equipment for Resident #11 and Resident #18, who required assistance and encouragement with eating. Findings include: I. Facility policy and procedure The Long-term care feeding policy, revised 12/11/23, was obtained from the corporate consultant (CC) on 11/7/24 at 3:41 p.m. It documented in pertinent part, Various disabilities and conditions may prevent a resident from self-feeding, including cognitive deficits, neuromuscular disease, cancer, obstructive lung disease, and traumatic injury. A resident who cannot self-feed is susceptible to malnutrition. The resident may also experience pain, nausea, depression, and anorexia as a result of the condition or its…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#10) of two residents reviewed for pressure injuries out of 20 sample residents received care and services necessary to prevent the development of pressure injuries. Specifically, the facility failed to ensure staff consistently followed the care planned wound prevention interventions for Resident #10, who had a facility-acquired pressure ulcer. 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 10/8/24, Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with non blanchable redness of a localized…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide respiratory care services for one (#8) of two residents reviewed for respiratory care services out of 20 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #33. Findings include: I. Facility policy and procedure The Oxygen Administration, Long Term Care, [NAME] policy and procedures, revised 12/11/23, was provided by the director of nursing (DON). According to the procedures, oxygen administration supplies the body with enough oxygen to meet its cellular needs. The implementation of oxygen administration required verifying the practitioner's (physician) orders, assisting in the placement of the prescribed oxygen delivery device on the resident, making sure that the oxygen device fit properly and adjusting the oxygen flow rate as ordered. Staff should not administer oxygen nasal cannula at more than 2 (two) liters per minute (lpm) to a resident with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2024-11-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 that the medical record was complete and accurate in keeping with accepted standards of practice for one (#9) of two residents reviewed for skin breakdown out of 20 sample residents. Specifically, the facility failed to conduct an accurate and thorough assessment of a resident's skin. Findings include: I. Resident #9 A. Resident status Resident #9, age greater than age [AGE], was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included gastroesophageal reflux disease with esophagitis without bleeding, acquired absence of other specified parts of digestive tract, personal history of transient ischemic attack (TIA), cerebral infarction with without residual deficits, Personal history of malignant neoplasm of other organs and systems, dysphagia, oropharyngeal phase, muscle weakness and reduced mobility. The 10/15/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-13 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on three of four units and one of two dining rooms. Specifically, the facility failed to: -Ensure appropriate hand hygiene practices during meals and doffing personal protective equipment (PPE); -Ensure appropriate use of PPE such as masks; -Ensure medical equipment was disinfected after use; and, -Ensure high touch surfaces were disinfected after potentially contaminated items were placed on top of the surfaces. Findings include: I. Facility policy and procedure The Hand Hygiene policy, reviewed 8/19/22, was provided by the director of nursing (DON) on 4/11/23 at 10:12 a.m. The policy read in pertinent part: The hands are conduits for almost every transfer of potential pathogens from one patient to another, from 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.
- Potential for harm · D2023-04-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observations, record review and staff interviews the facility failed to provide services three (#23, #27 and #21) out of seven residents reviewed out of 26 sample residents according to professional standards of practice. Specifically, the facility failed to ensure: -Resident #23 and #27's blood pressure was monitored prior to the administration of a blood pressure medication; and, -Resident #21 skin assessment was performed underneath bilateral lower extremity fracture walking boots. Findings include: I. Blood pressure parameters A. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK532906 on 4/17/23. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockage of these receptors with beta-blocker medications can lead to many adverse effects. Bradycarida (low heart rate) and hypotension (low blood pressure) are two adverse effects…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#3, #27 and #21) of four residents reviewed out of 26 sample residents. Specifically, the failed failed to: -Ensure Resident #3 received care to prevent a mat from forming in her hair; and, -Ensure Resident #3, Resident #27 and Resident #21 received bathing according to their preference and plan of care. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised October 2021, was provided by the nursing home administrator (NHA) on 4/13/23 at 12:52 p.m. It revealed in pertinent part, Purpose: to assist resident in achieving maximum functional ability with dignity and self-esteem, to provide assistance to residents as necessary, to supervise and assess resident function in order to plan care to maintain optimum ADL function 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.
- Potential for harm · Dcited before2023-04-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one (#1) of one sample residents received care, consistent with professional standards of practice, to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable; and to promote healing, prevent infection and prevent new ulcers from developing. Specifically the facility failed to ensure appropriate interventions were in place and followed related to Resident 16's pressure ulcer. Findings include: I. Facility policy and procedures The Prevention and Treatment of Pressure Ulcers/Pressure Injury policy, last revised 11/22/22, was provided by the interim nursing home administrator (INHA) on 4/13/23 at 12:52 p.m. The policy documented the following pertinent information: It is the policy of (the facility) to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 record review and interviews, the facility failed to identify the use of the indwelling catheter in the medical record for one resident (#3) of one resident reviewed for catheter use out of 26 sample residents. Specifically, the facility failed to ensure an assessment of the indwelling catheter that included a comprehensive, interdisciplinary review identifying the underlying factors which support the clinical indication for the initiation and continued need for catheter use, the development of a plan for removal, consideration of complications resulting from the use of an indwelling catheter, insertion, ongoing care that adhered to professional standards of practice and infection prevention and control procedures; and ongoing monitoring for changes related to potential catheter associated urinary tract infections (CAUTIs). Findings include: I. Facility policy and procedure The Indwelling Urinary Catheter (foley) Care and Management policy, dated 11/28/22, was provided by the nursing home administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure each resident received necessary respiratory care and services that is in accordance with professional standards of practice and the resident's care plan for one (#21) of three residents reviewed for oxygen therapy out of 26 sample residents. Specifically, the facility failed to ensure Resident #21 received oxygen therapy in accordance with the physician's order. Findings include: I. Professional reference [NAME]/[NAME]/[NAME]/[NAME]/[NAME], Lewis's Medical-Surgical Nursing Assessment and Management of Clinical Problems, eleventh edition, 2019, page 566. Oxygen Therapy is often used in the treatment of COPD (chronic obstructive pulmonary disease) and other problems associated with hypoxemia (low levels of oxygen in the blood). Used clinically, it is considered a prescribed medication. II. Facility policy The Oxygen Administration, Long-Term Care policy, revised 11/28/22, was provided by the nursing home administrator (NHA) on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for two (#21 and #3) out of 26 sample residents. Specifically, the facility failed to: -Offer non-pharmacological pain interventions for Resident #21; -Determine an acceptable pain level for Resident #21 and #3; and, -Administer pain medications per physician's order for Resident #3. Findings include: I. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, nondisplaced fracture of medial malleolus of right tibia (right ankle fracture, nondisplaced fracture of lateral malleolus of left fibula (left ankle fracture), anxiety disorder, heart disease,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-01-19 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for three (#11, #21 and #40) of five residents reviewed for bathing preferences out of 24 sample residents. Specifically, the facility failed to provide routine bathing consistent with the residents' preferences for Resident #11, #21 and #40. Findings include: I. Facility policy The [NAME] of Rights for Nursing Home Patients, dated March 2014, was provided by the nursing home administrator (NHA) on 1/19/22 via email. According to the bill, residents have the right to know that choices are available to them and they have the right to make independent personal decisions. The Tub Bath/Showers and Bed Baths policy, revised November 2021, was provided by the nursing home administrator (NHA) on 1/19/22 via email. The policy read in part: Based on the comprehensive assessment of a resident and consistent with the resident's needs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-01-19 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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, observations and interviews, the facility failed to ensure three (#9, #31 and #5) of five residents reviewed out of 24 sample residents were free from abuse by Residents #37, #5, #11 and #31. Specifically, the facility failed to ensure: -Resident #9 was free from verbal abuse by Resident #37; -Resident #31 was free from sexual abuse by Residents #5 and #11; and, -Resident #5 was free from physical abuse by Resident #31. Cross-reference F609 failure to report abuse, F610 failure to thoroughly investigate abuse and F742 mental health and behavioral services. Findings include: I. Facility policy The Freedom from Abuse, Neglect and Misappropriation Policy and Procedure, revised November 2016, provided by the director of nursing (DON) on the morning of 1/16/22, documented in pertinent part: Each individual has the right to be free from verbal, sexual, physical and mental abuse, including but not limited to, staff and other residents. The facility's population presents the following factors…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-01-19 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to thoroughly investigate abuse allegations involving five (#9, #37, #31, #5 and #11) of six out of 24 sample residents reviewed. Specifically, the facility failed to thoroughly investigate: -Resident #9's verbal abuse by Resident #37; -Resident #31's sexual abuse by Residents #5 and #11; and -Resident #5's physical abuse by Resident #31. Cross-reference F600 failure to ensure residents were free from abuse, F609 failure to report abuse, and F742 mental health and behavioral services. Findings include: I. Facility policy The Freedom from Abuse, Neglect and Misappropriation Policy and Procedure, revised November 2016, was provided by the director of nursing (DON) on the morning of 1/16/22. The investigation portion of the policy documented in pertinent part: The investigation is the process used to try to identify what happened. The nurse begins the investigation immediately. The information gathered is given to administration. The investigation will include: -Who was involved -Residents' statements -Involved staff and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-19 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 identify and report abuse incidents involving two (#37 and #31) of six out of 24 sample residents reviewed to the State Survey and Certification Agency. Specifically, the facility failed to identify as abuse and report: -Resident #37's ongoing incidents of verbal abuse and threatening behavior directed toward other facility residents; and, -Resident #5's physical abuse by Resident #31. Cross-reference F600 failure to ensure residents were free from abuse, and F742 mental health and behavioral services. Findings include: I. Facility policy The Freedom from Abuse, Neglect and Misappropriation Policy and Procedure, revised November 2016, was provided by the director of nursing (DON) on the morning of 1/16/22. The reporting portion of the policy documented in pertinent part: Employees must always report alleged abuse/neglect immediately to the supervisor. The executive director must be contacted immediately by the supervisor or reporter regarding all allegations of abuse/neglect. If there is suspicion that abuse occurred, it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-19 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents identified with a mental disorder (MD) or intellectual disorder (ID) were evaluated and received care and services in the most integrated setting appropriate to their needs for one (#18) of one resident reviewed for pre admission screening and resident review (PASRR) of 24 sample residents. Specifically, the facility failed to ensure Resident #18 had a follow up PASRR after initial evaluation, dated 4/9/21, determined revaluation was needed within 30 days. Findings include: I. Facility policy and procedure A Pre-admission Screening Process policy, last revised March 2011, was provided by the social services director (SSD) on 1/19/22. The policy read: All potential admissions are screened prior to admission to ensure the facility care can provide the necessary care to the individual prior to admission. -The SSD said that this was the most up to date policy the facility had, however she followed the Colorado Department of Public Health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-19 · tag F0742 — isolatedProvide 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 record review and interviews, the facility failed to provide mental health care and services for one (#37) of two residents reviewed out of 24 sample residents. Specifically, the facility failed to identify and provide for Resident #37's mental health needs. Resident #37 exhibited anxiety, adjustment difficulty and distress, and exhibited verbally abusive behaviors toward other residents. Resident #37 resided in the memory care neighborhood with 10 other vulnerable residents. Cross-reference F600, failure to protect residents from abuse. Findings include: I. Facility policy The Behavioral and Mental Health Services policy, dated December 2016, was provided by the nursing home administrator (NHA) via email on 1/20/22. The policy documented: The facility must provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Procedure: 1. Based on assessment, the facility must ensure that a resident who displays or is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$11,180 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $11,180 — penalty dated 2023-09-05
- Medicare payment denial — starting 2023-10-04 for 2 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 VOLUNTEERS OF AMERICA SENIOR LIVING — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 4.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 3.4 | -1.4 vs chain |
The other 5 homes this chain runs (chain average 3.2★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| VOLUNTEERS OF AMERICA NATIONAL SERVICES | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/16/2015 |
| BLOOM, SHAWN | Individual | CORPORATE DIRECTOR | since 03/23/2010 |
| ERICKSON, KAREN | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| HACKETT, KAREN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/01/2023 |
| JACKSON, CARMEN | Individual | CORPORATE DIRECTOR | since 07/01/2025 |
| MULLEN, BETH | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/01/2023 |
| PERKINS, DERRICK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 07/01/2019 |
| PETERSON, JEANNE | Individual | CORPORATE DIRECTOR | since 07/01/2017 |
| SHERIDAN, PATRICK | Individual | CORPORATE DIRECTOR | since 07/01/2023 |
| STRINGFELLOW, JANET | Individual | CORPORATE DIRECTOR | since 07/01/2024 |
| VIGEE, VORIS | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| BEATY, DEJERNETTE | Individual | CORPORATE OFFICER | since 07/01/2025 |
| BUDZYNSKI, JOSEPH | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 04/02/2012 |
| CHAKRAVARTY, DEBASHISH | Individual | CORPORATE OFFICER | since 07/01/2025 |
| KING, MICHAEL | Individual | CORPORATE OFFICER | since 07/01/2010 |
| NISIVOCCIA, DAVID | Individual | CORPORATE OFFICER | since 07/01/2024 |
| NUTZ, FAITH | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 09/01/2018 |
| PASKOFF, DAVID | Individual | CORPORATE OFFICER | since 07/01/2024 |
| FUNK, DORY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2013 |
| JONES, RONDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/27/2023 |
| SOCZYNSKI, PAUL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/20/2025 |
CMS files one row per role, so the 31 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Colorado Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 065258. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-07, 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.