Rehabilitation And Nursing Center Of The Rockies
1020 Patton St, Fort Collins, CO 80524 · For profit - Corporation · 106 certified beds · (970) 484-7981 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0610), cited Jun 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $21,721 in federal fines (most recent 2025-06-26)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 fell from 4 to 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 | 7.9% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.8% | 4.7% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.2% | 8.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.6% | 13.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 14.4% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 34.4% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.0% | 20.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 71.3% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.9% | 20.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.3% | 12.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.15 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.79 | 1.74 | 1.80 | better |
§ 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.
56.9% 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 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 74 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.54 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 56.9%CMS range 46.0–65.9 | 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 | 10.1%CMS range 7.1–14.0 | 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 | 73.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 67.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | 93.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 92.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 2.9% | 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 4.1–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 106 beds and averages 87.7 residents a day — about 83% occupied, or roughly 18 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 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 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 2.69 hrs/resident/day on weekends vs 3.47 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.58 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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.
21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.
- Immediate jeopardy · J2025-06-26 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY IV. Resident #4 - The facility failed to initiate a thorough investigation of an injury of unknown origin. A. Resident #4 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included systemic involvement of connective tissue (autoimmune disease), arthritis, edema, and history of stroke. The 6/3/25 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 14 out of 15. The resident required total assistance (fully dependent) from the staff for toileting, dressing, bed mobility (the ability to sit up or roll from side to side while lying), and all transfers. The resident required (two-person) extensive assistance from the staff for bathing and personal hygiene. Resident #4 had impairments to her lower extremities and a limited full range of motion. 2. Resident interview Resident #4 was interviewed on 6/25/25 at 4:00 p.m. She said she sustained an injury in the middle of May 2025 when a male CNA she did not know came into her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-06-26 · 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 two (#4 and #207) of eight residents reviewed for accident hazards received adequate supervision out of 37 sample residents. Resident #4 was admitted to the facility for long term care on 4/5/24 with diagnoses of systemic involvement of connective tissue (autoimmune disease), arthritis, edema and history of stroke. Resident #4 was identified as cognitively intact and was able to transfer with a sit-to-stand mechanical lift (a lift device used to enhance a resident's dignity and independence by helping residents who can bear weight and participate to transition from a seated to a standing position). Resident #4 said a male certified nurse aide (CNA) transferred her without utilizing the sit-to-stand mechanical lift in May 2025. She said while the CNA was transferring her, they heard a pop. Resident #4 expressed pain and was observed by staff to have bruising, swelling, and redness to her right leg, ankle and foot. The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-23 · 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 interviews, the facility failed to ensure services met professional standards of practice for one (#9) of eight residents out of 13 sample residents.Specifically, the facility failed to:-Ensure nurses did not leave medications on Resident #9's bedside table; -Ensure Resident #9 when he was administered his medications to make sure he swallowed them; and; -Ensure nurses did not document in Resident #9's medication administration record (MAR) that the resident's medications were administered/swallowed when they were not.Findings include:I. Facility policy and procedureThe Medication Administration policy, revised December 2024, was provided by the regional nurse consultant (RNC) on 9/22/25 at 2:47 p.m. The policy revealed medications should be administered as prescribed by the attending physician. Medications may not be set up in advance and must be administered within one hour before or after their prescribed time. The staff administering the medication must record such…
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 · D2025-09-23 · 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 observations, record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#5) of eight residents reviewed for medical record accuracy out of 13 sample residents. Specifically, the facility failed to ensure accurate documentation of Resident #5's medication administration for Cardura (medication used to treat high blood pressure).Findings include:I. Facility policy and procedureThe Medication Administration Documentation policy and procedure, revised August 2025, was received from the regional nurse consultant (RNC) on 9/23/25 at 1:17 p.m. It read in pertinent part, It is the policy of this facility that medication administration should be documented as per physician order and to reflect if the resident accepted medication administration All current drugs and dosage schedules must be reported on the resident's medication administration record (MAR). Should a drug be withheld, it should be appropriately documented…
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 · E2025-06-26 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and follow up with residents on the outcomes and resolutions of grievances expressed. Findings include: I. Facility policy and procedure The Grievance policy, reviewed June 2025, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:42 p.m. It read in pertinent part, The grievance official or designee responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken in resolution. II. Resident group interview Four residents (#14, #11, #8 and #54) who regularly attended the resident council meetings were interviewed on 6/25/25 at 9:00 a.m. The residents were identified as alert and oriented by the facility and assessment. The group of residents said the facility did not follow up on grievances brought up in the resident council meetings. Resident #14 said when a grievance came up 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.
- Potential for harm · D2025-06-26 · tag F0555 — isolatedHonor the resident's right to choose his or her attending physician.
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 one (#52) of five residents had the right to choose her own attending physician out of 37 sample residents. Specifically, the facility failed to allow Resident #52 to choose their primary care provider (PCP) when the resident's previous primary care provider stopped seeing residents. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, revised June 2025, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:32 p.m. It read in pertinent part, The resident has the right to choose a personal attending physician (and be informed how to contact him or her), to be fully informed in advance about care and treatment, and, unless adjudicated incompetent or otherwise found incapacitated under state law, participate in planning medical treatment. II. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO),…
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 · D2025-06-26 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#207 and #21) of five residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 37 sample residents. Specifically, the facility failed to: -Ensure Resident #21's behavior care plan had resident specific behaviors and triggers identified; -Document consistent behaviors for Resident #207 and Resident #21 to justify the continued use of psychotropic medications; and, -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions, for Resident #207 and Resident #21's psychotropic medications. Findings include: I. Facility policy and procedure The Chemical Restraint and Psychotropic Medication Management policy, dated April 2025, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:42 p.m. It read in pertinent part, The facility's interdisciplinary team (IDT) will review the comprehensive assessment to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 and document sufficient discharge preparation and documentation for one (#99) of three residents reviewed for a safe and orderly discharge out of 37 sample residents. Specifically, the facility failed to ensure thorough documentation, including physician notification, when Resident #99 and her representative left the facility against medical advice (AMA). Findings include: I. Resident #99 A. Resident status Resident #99, age [AGE], was admitted on [DATE] and left the facility to her representative's home on 4/2/25. According to the April 2025 computerized physician orders (CPO), diagnoses included anxiety, fracture of patella and hypertension. The 4/1/25 minimum data set (MDS) assessment revealed an assessment had not been completed for Resident #99. B. Resident representative interview The resident's representative was interviewed on 6/24/25 at 10:12 a.m. The representative said Resident #99 was admitted to the facility after a fall with 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 · D2025-06-26 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#21) of five residents reviewed for PASRR out of 37 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR Level II notice of determination (NOD) for Resident #21. Findings include: I. Professional reference The National Center for Biotechnology Information, National Library of Medicine guidance website, dated 5/16/23, retrieved on 7/1/25, from http://www.ncbi.nlm.nih.gov/books/NBK513310 read in pertinent part, A neurocognitive assessment, also known as cognitive testing or a neuropsychological evaluation, is a series of tests designed to measure various aspects of brain function. Neuropsychological evaluations require the use of standardized instruments…
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 · D2025-06-26 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one (#78) of five residents reviewed for activities out of 37 sample residents received an ongoing program of activities designed to meet their needs and interests, and promote physical, medical, and psychosocial well-being. Specifically, the facility failed to offer and provide a personalized activity program for Resident #78. Findings include: I. Facility policy and procedure The Activities policy and procedure, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 4:32 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate. II. Resident #78 A. Resident status Resident #78, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included dementia with agitation, anxiety disorder and insomnia. The [DATE] minimum data…
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 · D2025-06-26 · 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 ensure one (#23) of five residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 37 sample residents. Specifically, the facility failed to identify Resident #23 had a history of suicidal ideation in order to monitor for worsening signs and symptoms of depression or suicidal ideation. Findings include: I. Facility policy and procedure The Suicide Precaution policy and procedure, revised August 2022, was provided by the nursing home administrator (NHA) on 6/27/25 at 4:32 p.m. It read in pertinent part, If a resident verbalizes an intent to attempt suicide or takes any action that could be interpreted as a suicide attempt, document specific behavior and or statements of the resident, notification of physician and family or responsible party, safety interventions and actions taken. II. Resident #23 A. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 facility resources were administered in a manner that allowed its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. Specifically, the facility failed to: -Provide sufficient leadership to address and or avoid multiple concerns; -Prevent, report and fully investigate allegations of abuse timely to provide immediate protections to residents at risk; -Report and investigate an injury of unknown origin in a timely manner so that an accurate timeline of events could be established and the injury could be effectively treated and monitored; and, -Monitor a resident for worsening symptoms of depression who expressed suicidal ideations. Findings include: I. Abuse and neglect During the extended survey from 6/23/25 to 6/26/25, it was identified that there were concerns over the timely reporting of an allegation of abuse so that the resident could be immediately protected from a repeat incident 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.
Show the remaining 9 citations
- Potential for harm · D2025-06-26 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeeping staff performed appropriate hand hygiene between cleaning resident rooms; -Ensure staff kept clean and soiled laundry separate in the laundry room; -Ensure staff handled plastic drinking cups in a hygienic manner to prevent contamination; and -Provide tracheostomy care for Resident #34 in a sanitary manner; and, -Ensure that Resident #95's urinary catheter drainage bag was cleaned appropriately and stored in a sanitary manner. Findings include: I. Failed to ensure housekeeping staff performed appropriate hand hygiene between cleaning resident rooms A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Hand Hygiene in Healthcare Settings, revised 1/18/21,…
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 · E2024-10-23 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 interview, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for three (#3, #12 and #9) of four residents out of 20 sample residents. Specifically, the facility failed to ensure Resident #3, #12 and #9 received timely person-centered assistance with meal set up and/or eating. Findings include: I. Facility policy and procedure The Activity of Daily Living policy, reviewed September 2023, was received from the director of nursing (DON) on 10/23/24 at 11:30 a.m. The policy read in pertinent part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff to maintain eating, grooming, personal hygiene, communication, oral hygiene, transfers and ambulation. ADLs will be care planned to reflect…
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 before2024-10-23 · 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 observation, interview and record review the facility failed to provide adequate supervision during use of assistive devices to keep residents free from safety hazards for two (#10 and #11) of three residents out of 20 sample residents. Specifically, the facility failed to ensure wheelchair pedals were attached to Resident #10's and Resident #11's wheelchairs prior to pushing the residents within the facility. I. Facility policy and procedure The Fall Management System policy, reviewedNovember 2023, was received from the director of nursing (DON) on 10/22/24 at 4:55 p.m. The policy read in pertinent part, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. II. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-01 · 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 one (#2) of three residents out of nine sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure identified person-centered fall interventions, which were care planned, were implemented consistently for Resident #2 following a fall with a left wrist fracture. Findings include: I. Facility policy and procedure The Fall Management System policy policy, dated 11/2023, was provided by the director of nursing (DON) on 5/1/24 at 11:26 a.m. It read in pertinent part, It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls. Care plan interventions will be developed to prevent falls. II. Resident #2 status Resident #2, age under 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included paraplegia, contractures to ankles, pressure ulcer and type I diabetes mellitus.…
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 · D2024-05-01 · 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 record review and interviews, the facility failed to manage the pain of two (#7 and #8) of three residents out of nine sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to ensure pain medication had documented parameters for Resident #7 and Resident #8. Findings include: I. Professional reference The American Medical Directors Association (AMDA) The Society for Post-Acute and Long-Term Care Medicine Pain in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline.[NAME], MD (2021), retrieved on 5/8/24 from www.paltc.org, read in pertinent part, When several options for administering analgesics are ordered for a patient, nursing staff need adequately detailed guidance concerning how and when to select a PRN medication from among the several options that have been ordered. II. Facility policy and procedure The Pain Recognition and Management…
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 · D2023-12-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#65) of one resident reviewed for respect and dignity out of 40 sample residents. Specifically, the facility failed to: -Ensure Resident #65 was treated with respect and dignity from facility staff after she reported concerns; -Ensure Resident #65 was offered alternative activities when facility administration requested she not enter the activities hallway; -Ensure Resident 65's care plan was updated to with her involvement, included accurate resident needs and interventions; and, -Ensure Resident #65's concerns and interventions were documented in her medical record. Findings include: I. Facility policies The Promoting/Maintaining Resident Self-Determination, revised March 2023, was received by the nursing home administrator (NHA) on 12/12/23 at 8:50 a.m. 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 · D2023-12-12 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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, interview and record review, the facility failed to ensure one (#74) of one resident reviewed for dementia care out of 40 sample residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop a comprehensive plan of care, to include person-centered interventions to engage Resident #74 and address his wandering behaviors. Findings include: I. Facility policy and procedure The Dementia care policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 12/7/23 at 4:05 p.m. The policy read in pertinent part: It is the policy of this facility that all residents will have an individualized plan of care and have the least restrictive approaches to care; The staff are offered specialized training in the care of the dementia population, appropriate approaches to care and managing behaviors; 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.
- Potential for harm · D2019-11-21 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for convenience and were not required to treat medical symptoms for one (#39) of one resident reviewed for restraints out of 31 sample residents. Specifically, the facility failed to: - perform an initial assessment and subsequent quarterly assessments for the use of a lap belt, - obtain a physician's order with a specific medical diagnosis for the use of a lap belt, - obtain a consent from the resident's medical durable power of attorney (MDPOA) prior to the use of a lap belt, - develop a monitoring system for the safe utilization of a lap belt, and - develop a care plan to reflect the interventions that address not only the immediate medical symptoms, but the underlying problems that might be causing the symptoms. The plan also did not include the measures taken to systematically reduce or eliminate the need for the lap belt. Findings include: I. Facility policy The Use 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.
- Potential for harm · Dcited before2019-11-21 · 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 interviews, the facility failed to provide services that met professional standards of quality according to accepted standards of clinical practice for one (#2) of one resident reviewed for care and services out of 31 sample residents. Specifically, the facility failed to follow physician orders for notification of weight gain with parameters which lead to a possible delay in treatment. Findings include: I. Facility policy The Physician's Orders policy, revised March 2011, was provided by the director of nursing (DON) on 11/20/19 at 1:53 p.m. The policy revealed, the facility would obtain physician orders in a timely manner. The nurse would follow the providers order as written or directed. If for any reason the provider's orders were not followed as written or directed, the nurse must: notify the provider immediately for further instructions. The nurse would also notify the DON or designee and monitor the resident for any change of condition. II. 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.
“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
$21,721 in federal fines across 1 penalty.
- $21,721 — penalty dated 2025-06-26
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 ENSIGN GROUP — 342 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 | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
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 |
|---|---|---|---|
| CHOHAN, JAMEEL | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 04/09/2025 |
| TRUAX, TODD | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/09/2025 |
| BURNAM, SOON | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 08/01/2023 |
| GRAHAM, JOSEPH | Individual | CORPORATE OFFICER | since 02/01/2024 |
| JORGENSEN, DAVID | Individual | CORPORATE OFFICER | since 08/01/2023 |
| SATO, AMI | Individual | CORPORATE OFFICER | since 09/09/2024 |
| MASON HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 08/01/2023 |
| STANDARD BEARER HEALTHCARE OP LP | Organization | ADP OF THE SNF | since 08/01/2023 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | since 08/01/2023 |
CMS files one row per role, so the 13 rows in the source record cover these 9 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.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $323K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CO
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 065192. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.