Bruce McCandless Co State Veterans Nursing Home

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.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 46% 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 105 beds and averages 60.8 residents a day — about 58% occupied, or roughly 44 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 3.77 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.24 hrs/resident/day on weekends vs 3.99 on weekdays — 19% thinner on weekends. RN hours go from 1.98 to 1.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

20 citations, most serious first. The 14 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-01-29 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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, observations, and interviews, the facility failed to provide a safe environment and protect residents from resident-to-resident abuse, involving nine of ten residents reviewed (#15, #3, #68, #27, #70, #46, #6, #50 and #59) out of 33 sample residents. Record review and staff interviews revealed Resident #68, significantly cognitively impaired and with a history of trauma, was the victim of four incidents of resident-to-resident physical abuse (11/8/25, 11/25/25 (twice) and 12/3/26).The abusive incidents contributed to the resident being physically abused (shoved, pushed, grabbed, and hit in the face and head), and sustaining physical harm (abrasions, facial contusions) and psychosocial harm (fear, anxiety, agitation, distress (crying). Record review revealed additional incidents of resident-to-resident abuse (hitting, shoving, threats of harm) involving Residents #50, #3, #15, #59, #46 and #6. Record review revealed that facility staff and administration failed to put effective…

  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 before2024-06-06 · 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 record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#49) of eight residents reviewed for accident hazards out of 34 sample residents. Resident #49 was identified as a high fall risk through facility assessment. Resident #49 needed substantial to maximum assistance rolling from left to right/right to left in bed. Resident #49's care plan was reviewed on 4/4/24 and included an intervention for the assistance of two people with bed mobility (scooting, rolling, or moving from lying to sitting or sitting to lying) and transfers in and out bed. Resident #49 sustained a fall out of bed on 4/11/24 while receiving incontinence care from certified nurse aide (CNA) #1. CNA #1 was providing care for the resident without another staff member in the room for assistance. When CNA #1 rolled the resident toward her, the resident rolled too far over and began to fall off the bed. CNA #1 was unable to catch the resident and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2020-02-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to implement appropriate and timely interventions to ensure two (#71 and #46) out of five residents reviewed for pressure ulcers received the necessary care and treatment to prevent the development of a pressure injury (ulcer), out of 37 sample residents. Specially the facility failed to ensure: -Necessary interventions to assist Resident #71, despite the facility being aware of the resident's compromised health and skin condition, contributed to the resident developing a stage three (3) pressure ulcer to the coccyx. -Resident #71 with pressure relief, timely incontinent care and friction reduction, to prevent the development of a moisture induced stage three (3) pressure injury. Interventions to change and reposition the resident were not implemented timely, in order to maintain the resident's skin integrity and promote healing. -Resident #46's fingernails were trimmed to prevent pressure from his fingernails digging into his left palm.…

  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 before2020-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews the facility failed to reduce the risk of all known or foreseeable accident hazards that cannot be eliminated and ensure that each resident received adequate supervision and assistance devices to prevent accidents, for two (#29 and #53) of three residents reviewed for falls out of 37 sample residents. Specifically, the facility failed to ensure Residents #29 and #53 were free from continued falls. The facility failed to: -Ensure each resident (#29 and #53) were fully assessed following each fall episode for all possible accidents/hazards factors which might result in a fall. -Ensure each resident (#29 and #53) were provided consistent oversight, supervision and monitoring while engaged in known impulsive and unsafe behaviors. -Ensure each resident (#29 and #53) received prescribed fall interventions consistently and effectively. -Ensure a thorough assessment to consider all possible causes of the residents' falls. -Ensure that all staff were fully trained 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-01-29 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for two of two medication storage rooms. Specifically, the facility failed to:-Ensure medications were labeled with the date they were opened; and, -Ensure expired medications were properly disposed of. Findings include:I. Facility policy and procedureThe Medication Storage policy, revised 1/9/26, was received from the nursing home administrator (NHA) on 1/29/26. The policy read in pertinent part, It is the policy of the facility to ensure that all medications housed on the premises should be stored in the pharmacy, medication rooms and/or carts according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Medication storage areas should be routinely inspected by the designee for discontinued, outdated,…

  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 · D2026-01-29 · tag F0679 — failed to provide activities — isolated
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to provide activities that meet the interest and needs of the residents on the secure memory care unit.Specifically, the facility failed to provide meaningful and person centered activities for residents residing in a secure memory care unit (cross-reference F600 for abuse). Findings include:I. Observations During an initial walk through of the facility on 1/25/26 at approximately 9:00 a.m., a facility activities calendar was observed on the non secure side of the facility. It did not indicate any specific activities for the secure memory care unit. On the secure memory care unit, there was no posted activities calendar observed. During a continuous observation on the secure memory care unit on 1/26/26 beginning at 8:08 a.m. and ending at 1:21 p.m. the following was observed:Resident #27 was observed at 8:08 a.m. until 11:03 a.m. wandering without purpose. Resident #27 frequently stood near the windows looking out or pacing back and forth without interjection from the staff. At 11:12 a.m., Resident #27 was taken to his room…

  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 · D2026-01-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#11) of two residents who required respiratory care received care consistent with professional standards of practice out of 33 sample residents.Specifically, the facility failed to:-Follow physician's orders to maintain, clean, sanitize and store Resident #11's continuous positive airway pressure (CPAP) mask and machine; and, -Ensure a care plan was in place to include settings, cleaning, disinfecting and storage of the CPAP for Resident #11.Findings include:I. Facility policy and procedureThe Noninvasive Ventilation (CPAP) policy, revised 1/8/26, was provided by the nursing home administrator (NHA) on 1/27/26 at 3:05 p.m. The policy revealed in pertinent part, Noninvasive ventilation systems (CPAP, BiPAP) vary by manufacturer. Common equipment includes the machine, tubing, mask, headgear/straps, disposable/non-disposable filters, and humidifier chamber.The facility should follow the manufacturer's instructions for use of the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-29 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to maintain an infection control programdesigned to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to ensure Resident #24's catheter drainage bag was not stored on the floor to prevent potential contamination. Findings include:I. Facility policy and procedureThe Indwelling Catheter Care policy, revised 11/5/25, was provided by the nursing home administrator (NHA) on 1/27/26 at 3:05 p.m. The policy revealed in pertinent part, It is the policy of the facility to ensure residents with indwelling catheters receive appropriate catheter care to maintain their dignity, privacy and receive adequate care when indwelling catheters were in use. Catheter care should be performed every shift and as needed by nursing personnel. Privacy bags should be available and catheter drainage bags should be covered at all times while in use. Ensure the drainage bag is located below the level of the bladder to discourage backflow of…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-06-06 · tag F0658 — failed to meet professional standards of care — pattern
  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 observations, record review and staff interviews, the facility failed to ensure four (#10, #26, #21, #44) of eight out of 34 sample residents were provided services that meet professional standards of quality. Specifically, the facility failed to: -Clarify the physician's orders with dose information for Residents #10, #26, #21 and #44 for Voltaren gel (topical pain medication); and, -Ensure Resident # 21 received follow up care with the urologist. Findings include: I. Failure to clarify physician's orders with dose information for Voltaren gel A. Professional reference According to the Voltaren gel drug information, retrieved on 6/4/24 from https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. Voltaren is a nonsteroidal anti-inflammatory (NSAID) medication that can be prescribed in intravenous, oral, topical, and ophthalmic formulations. The use of analgesic and antipyretic properties increases the risk of serious gastrointestinal events and may increase serious cardiovascular events;…

  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 · E2024-06-06 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 use a person centered approach when determining the use of bed rails and transfer poles for three (#12, #10 and #20) of eight residents reviewed for accident hazards out of 34 sample residents. Specifically, for Residents #12, #10 and #20, the facility failed to: -Review the risks versus the benefits of using a bed rail with the resident or the resident's representative prior to use; -Obtain informed consent for the installation and use of bed rails prior to use; -Obtain physician's orders for bed rails; and, -Conduct routine maintenance of the bed rails to evaluate the continued safety of the bed rails. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA) Recommendations for Health Care Providers Using Adult Portable Bed Rails (2/27/23) was retrieved on 6/12/24 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-06-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to take steps to protect two (#35 and #36) of two residents reviewed for abuse out of 34 sample residents. Specifically, the facility failed to prevent a physical altercation between Resident #36 and Resident #35. Findings include: I. Facility policy The Abuse policy, revised 10/16/23, was provided by the nursing home administrator (NHA) on 1/22/24 at 2:30 p.m. It read in pertinent part, Every resident has the right to be free from mistreatment, abuse, neglect and exploitation. Staff will receive annual education in prevention of abuse and include the following topics: Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect, such as aggressive reactions of residents, outbursts or yelling out, and difficulty in adjusting to new routines or new staff. Identification of Abuse/possible indicators of abuse: physical abuse of a resident is observed; and verbal abuse of a resident is overheard. Residents at risk for abuse…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 treatment and care in accordance with professional standards of practice for one (#10) of one resident out of 34 sample residents. Specifically, the facility failed to ensure Resident #10's blood pressure medication was consistently held when her diastolic blood pressure (the bottom number of a blood pressure reading) was below the physician ordered parameters. Findings include: I. Professional reference: According to [NAME], P.A. A.G., et al., Fundamentals of Nursing, 10 ed. (2022) E. [NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-06 · tag F0881 — failed to use antibiotics responsibly — isolated
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program which included antibiotic use protocols and a system to monitor antibiotic use for one (#21) of one resident out of 34 sample residents. Specifically, the facility failed to effectively track and monitor the use of long-term and short-term antibiotics prescribed for Resident #21. Findings include: I. Professional reference According to The Centers for Disease Control and Prevention (CDC) Antibiotic Prescribing and Usage in Hospitals and Long-term Care, (2019), retrieved on 6/5/24 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/index.html, Implement policies that apply in all situations to support antibiotic prescribing, including specifying the dose, duration, and indication for all courses of antibiotics so that they are readily identifiable. Implement facility-specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2020-02-27 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure four (#10, #61, #50, and #34) of seven residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, hygiene, dressing and grooming, out of 37 total sample residents. Specifically, the facility failed to provide: -Timely dining assistance to Residents #61, #50 and #10; and -Scheduled showers for Resident #34. Findings include: I. Timely meal assistance A. Facility policy and procedure The Competency Steps: Assisting the Resident with Food and Drink Intake (Dependent Eating) policy and procedure, last revised 7/7/14, was provided by the nursing home administrator (NHA) on 2/27/2020 at 2:45 p.m. The document read in pertinent part: Critical elements: -Converse with residents during meal. Inform the resident what type of food and fluids that you are offering during the meal. -Never make the resident feel that the meal must be hurried. -Give him or her your complete…

  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

$52,988 in federal fines across 1 penalty.

• $52,988 — penalty dated 2026-01-29

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.

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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