Poudre Canyon Rehabilitation And Nursing, LLC

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 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 83 beds and averages 69.7 residents a day — about 84% occupied, or roughly 13 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.65 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.63 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.51 hrs/resident/day on weekends vs 2.70 on weekdays — 7% thinner on weekends. RN hours go from 0.51 to 0.40 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 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.

36 citations, most serious first. The 15 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-01-22 · 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 III. The facility failed to ensure Residents #168, #169, and #25 were free from physical abuse from Resident #43. Resident #43 had a history of physical altercations. He hit Resident #168, pushed Resident #169, and grabbed and shoved Resident #25. A. Facility policy and procedure The Abuse policy and procedure, revised on 6/11/24, was provided by the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, Every resident has the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. B. Incident on 5/13/24 between Resident #43 and Resident #168 1. Facility investigation A 5/13/24 abuse investigation documented there was a witnessed physical altercation between two residents. The residents were separated, assessed, and placed on one-to-one monitoring. Resident #168 said her fingers hurt and an x-ray was ordered. Resident #43 was interviewed on 5/13/24 and when asked if he grabbed another…

  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 before2025-05-15 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#10) of five residents reviewed for medication management were free from significant medication errors out of 22 sample residents. Resident #10 was admitted to the facility on [DATE] with a diagnosis of dementia. On 4/29/25 a nurse administered Resident #10 Lisinopril (used to treat high blood pressure), Metformin (used to treat diabetes), Seroquel (used to treat mental health conditions) and Ramelteon (used to treat insomnia). The resident began to experience severe hypotension (a dangerously low blood pressure) and was sent to the hospital. The resident received intravenous fluids and was monitored. Specifically, the facility failed to ensure Resident #10 did not receive another resident's (Resident #20) medications. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient…

  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
• Actual harm · Gcited before2025-01-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for two (#23 and #28) of five residents reviewed for accidents out of 38 sample residents. Resident #23, who was admitted on [DATE], required the use of a Hoyer lift (mechanical lift) and two-person staff assistance for transfers. Interviews during the survey revealed the resident had erratic body movements due to her diagnosis of anoxic brain damage (a condition caused by the brain being deprived of oxygen and leading to brain cell death). On 1/12/25, Resident #23 was being transferred by two staff members and hit her head on the bar of the Hoyer lift. The resident sustained a laceration to her head. Due to the facility's failures to ensure staff closely monitored the resident for erratic movements during Hoyer lift transfers, Resident #23 sustained a laceration to her head which required a transfer to the emergency department (ED) for seven sutures.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-06-16 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one resident (#32) had the right to a dignified existence out of 45 sample residents. Specifically, the facility failed to ensure Resident #32 experienced a dignified living experience by ensuring meals were served timely. Resident #32 said he felt frustrated, humiliated, sad and dehumanized by having to wait over 30 minutes for his meals when his tablemates had already been served, because he required staff assistance. The observations conducted during the survey process showed Resident #32 was the last individual to be served his meal in the dining room. He waited 27 minutes to receive his lunch meal on 6/13/22, after his tablemates had already been served. During this observation, the resident was yelling multiple times asking for his meal and became angry when his food did not arrive timely. Findings include: I. Resident #32 status Resident #32, younger than 65, was admitted on [DATE]. According to the June 2022 computerized…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure four (#62, #58, #27, and #6) of seven residents reviewed for accidents out of 45 sample residents remained as free from accident hazards as possible. Resident #62 sustained five falls in the facility within a six month period. The facility identified the resident's numerous fall risks (history of falls, cognitive impairment) but failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize her risks and keep her safe from injury. The resident's fourth fall on 4/8/22 resulted in a clavicle fracture, and the fifth fall on 4/14/22 in hematoma and laceration of her forehead. Additionally, the facility failed to: -Ensure effective interventions were evaluated and put into place after Resident #27 had sustained five falls; and, -Ensure an assessment by a registered nurse (RN) was completed and documented in the medical record for Resident #58 and Resident #6 following…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-15 · 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 IV. Failed to prevent two incidents of physical abuse of Resident #4 by Resident #22 A. First incident of physical abuse of Resident #4 by Resident #22 on 5/1/25 at 1:10 a.m. An incident report, dated 5/1/25 at 1:10 a.m. and written by LPN #6, related to an unwitnessed physical aggression, revealed LPN #6 and a CNA were on duty and heard yelling from down the hall and went to investigate. Resident #22 was observed walking out of Resident #4's room and began walking down Hall 200. The CNA went to check on Resident #22, while LPN #6 spoke with Resident #4 to ensure his safety. Resident #4 said Resident #22 hit him on his cheek. Resident #4 said that Resident #22 told him that the belongings in Resident #4's room were his (Resident #22's) and they were not. Resident #4 said he told Resident #22 the room was his room and then Resident #22 hit him on the cheek. When LPN #6 asked Resident #4 if he felt safe, he said that the police should be called because Resident #22 hit him on the cheek. Resident #4 said he was…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-15 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to report alleged violations of sexual and physical abuse to the State Survey and Certification Agency in accordance with state law for four of seven alleged abuse violations. Specifically, the facility failed to: -Submit a final report of the facility's investigation of two separate physical abuse allegations involving Resident #5 and Resident #4 to the State Agency within five calendar days of the incidents; -Submit a final report of the facility's investigation of a physical abuse allegation involving Resident #7 and Resident #8 to the State Agency within five calendar days of the incident; and, -Submit a final report of the facility's investigation of a sexual abuse allegation involving Resident #9 and a facility visitor to the State Agency within five calendar days of the incident. Findings include: I. Facility policy and procedure The Compliance with Reporting Allegations of Abuse/Neglect. Exploitation policy, reviewed on 5/7/25 (during the survey), was provided by the chief nurse officer (CNO) on 5/8/25 at 10:55 a.m.…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two of seven abuse allegations. Specifically, the facility failed to: -Thoroughly investigate an allegation of sexual abuse on 4/12/25 for Resident #9 in order to prevent a second incident from occurring on 4/23/25; and, -Thoroughly investigate an allegation of physical abuse between Resident #7 and Resident #8. I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 4/11/25, was provided by the director of nursing (DON) on 5/6/26 at 12:22 p.m. It read in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, the alleged perpetrator, witnesses, and others who might know about the allegations; focusing the investigation on determining if abuse has occurred, the extent,…

  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 · Ecited before2025-01-22 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review and interviews, the facility failed to serve food that was palatable and attractive. Specifically, the facility failed to ensure that the resident's food was palatable in taste, texture and appearance. Findings include: I. Resident interviews Resident #39 was interviewed on 1/13/25 at 11:49 a.m. He said that the food did not taste good and was not presentable. Resident #59 was interviewed on 1/13/25 at 2:10 p.m. He said that the food was not good. He said the taste of the food depended on who was cooking and what staff was working. Resident #44 was interviewed on 1/13/25 at 3:23 p.m. She said that the food tasted horrible and that the food does not look presentable. Resident #217 was interviewed on 1/13/25 at 3:37 p.m. She said the facility did not have an alternate menu. She said the kitchen would often close by the time she got her meal, so if she did not like what was served she could not get something else. Resident #50 was interviewed on 1/14/25 at 9:43 a.m. He said the food was not good. He said the food did not taste good. He said 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-01-22 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse that rose to the level of immediate jeopardy. Findings include: I. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies. F600 Abuse prevention During a recertification survey on 7/13/23, F600 was cited at a G level scope and severity, isolated, actual harm. The facility had identified and corrected the deficient practice prior to the survey and therefore F600 was cited at past non-compliance. -However, the facility failed to maintain compliance. During a recertification survey on 1/15/25, F600 was cited at K level scope 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-22 · 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 observations, record review and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two (#167 and #64) of five residents reviewed for quality of care out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #167's physician was notified in a timely manner when attempts to start an intravenous (IV) line were unsuccessful and staff could not administer IV fluids per the physician orders; and, -Ensure Resident #64's laboratory (lab) blood work was addressed by the resident's physician in a timely manner. Findings include: I. Facility policy The Change in a Resident's Condition or Status policy and procedure, revised 12/19/16, was received from the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, The nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there has been a change in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-22 · tag F0700 — isolated
  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 observation, record review, and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for one resident (#1) out of 38 sample residents. Specifically, for Resident #1, the facility failed to: -Assess the resident for the safe use of bed rails, including assessment for risk of entrapment prior to installing the bed rails; -Create and document a personal care plan for the safe use of bed rails; -Obtain consent from the resident and/or the resident's representative before bed rails installation, including informing them of the risks versus benefits of bed rails; -Obtain a physician's order for the bed rails; and, -Conduct quarterly assessments of the bed rails to evaluate their continued need and safety. Findings include: I. Facility policy and procedure The Side Rail policy, revised on 12/19/16 was received from the nursing home administrator (NHA) on 1/22/25 at 4:15 p.m. It read in pertinent part, An assessment of the resident will be made to include a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-22 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to ensure the medication administration error was not greater than five percent. Specifically, the facility's medication administration error rate was 8% (percent), or two errors out of 25 opportunities for error. Findings include: I. Manufacturer's recommendations The Novolog medication package insert (February 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.novo-pi.com/novolog.pdf. It revealed in pertinent part, Giving an air shot before injection (after needle application): before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. the dose selector should return to zero. A drop of insulin should…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-22 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for two (#18 and #46) of two residents reviewed for medications errors out of 38 sample residents. Specifically, the facility failed to ensure that Resident #18 and Resident #46 were administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Manufacturer recommendations The Novolog medication package insert (February 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.novo-pi.com/novolog.pdf. It revealed in pertinent part, Giving an air shot before injection (after needle application): before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-22 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart; and, -Ensure all medications were labeled with resident information. Findings include: A. Professional references The United States Food and Drug Administration (USFDA) (10/31/24) Don't Be Tempted to Use Expired Medicines, was retrieved on 1/23/25 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It documented in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$48,308 in federal fines across 2 penalties.

• $10,358 — penalty dated 2025-05-15
• $37,950 — penalty dated 2025-01-22

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 THE CHARLY BELLO FAMILY, THE MAZE FAMILY, THE SWAIN FAMILY, & WALTER MYERS — 19 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 13 rows in the source record cover these 11 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.

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

Follow the money — this home’s finances

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

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in CO