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Glenwood Springs Healthcare

2305 Blake Ave, Glenwood Springs, CO 81601 · For profit - Limited Liability company · 54 certified beds · (970) 945-5476 Medicare & Medicaid certified

Call the home — (970) 945-5476 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 2026Resident-funds citation (F0565)2 actual-harm citations$5,293 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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)
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $5,293 in federal fines (most recent 2023-09-05)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (82%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1906 Blake Ave · (970) 384-7707 · Call to confirm hours
Pharmacy
1906 Blake Ave · (970) 945-2202 · Call to confirm hours
Grocery
2828 S Glen Ave
Park
2001 Blake Ave · (970) 945-2614 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 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 improved from 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.7%13.4%15.4%better
Long-stay residents who lose too much weight0.8%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection2.2%1.4%2.0%worse
Long-stay residents with depressive symptoms5.7%8.8%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.4%3.4%3.3%worse
Long-stay residents whose ability to walk worsened14.5%13.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication15.8%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.7%95.3%typical
Long-stay residents with pressure ulcers4.2%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control9.6%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table31.8%20.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.6%1.4%better
Short-stay residents given the seasonal flu vaccine82.6%75.6%79.4%typical
Short-stay residents rehospitalized after admission22.0%20.3%22.6%typical
Short-stay residents with an outpatient ER visit9.0%12.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.911.381.67better
Long-stay outpatient ER visits per 1,000 resident days2.071.741.80worse

§ 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.

38.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.6%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
0.39U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF38.6%CMS range 27.0–49.351.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.7–16.410.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.5%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 3.5–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS 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

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
81.8%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 54 beds and averages 38.5 residents a day — about 71% occupied, or roughly 16 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.

Weekend coverage: total nurse staffing is 3.03 hrs/resident/day on weekends vs 3.54 on weekdays — 14% thinner on weekends. RN hours go from 0.86 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 82% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

7
deficiencies at the latest standard inspection (2024-10-17)
10
at the previous standard inspection (2023-03-30)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited beforedisputed · IDR2024-07-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#1) of three residents reviewed for pressure ulcers out of 39 sample residents. Resident #1, who was known to be at risk for pressure injuries, was admitted on [DATE] and readmitted on [DATE]. The resident had diagnoses of multiple sclerosis (disabling disease of brain and spinal cord), neurogenic bladder and metabolic encephalopathy (brain disorder caused by chemical imbalance of the blood). Hospital documentation recommended treatment for the wounds which were present to the Resident #1's sacrum, right lower extremity and left lower extremity upon the resident's readmission to the facility on 3/17/24. The recommendations further indicated the resident was to follow up with outpatient wound care. However, the facility failed to initiate a care plan and interventions to prevent the development of pressure injuries until 5/11/24. On 5/6/24,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2022-01-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed for pressure injuries, out of 26 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #11 had a facility acquired unstageable pressure injury which was not identified as unavoidable in the medical record. The review of the resident's progress notes and medical record between 11/11/21 and 1/10/22 did not identify the resident was seen by her primary physician or by a wound physician after it was identified the resident had an unstageable pressure injury/DTI (deep tissue injury). The review of the resident's medical record indicated the resident was not identified to have any skin related issues to her left heel until it was identified as unstageable on 11/11/21. The resident was at risk for developing pressure injuries according to the Braden scale risk assessment and the 10/21/21 minimum data set (MDS) assessment. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-21 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide reasonable accommodations for six (#9, #7, #8, #15, #2 and #13) of 10 residents out of 15 sample residents.Specifically, the facility failed to ensure call lights were within reach for Resident #9, Resident #7, Resident #8, Resident #15, Resident #2 and Resident #13.Findings include: I. Facility policy and procedure The Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. The policy read in pertinent part, Ensure that the call light system is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, chronic kidney disease and dysphagia. The minimum data set (MDS) assessment was not completed at 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to timely report an allegation of abuse involving two (#1 and #2) of six residents reviewed for abuse out of 15 sample residents.Specifically, the facility failed to:-Timely report an allegation of physical abuse by Resident #2 towards Resident #1; and,-Timely report an allegation of verbal abuse by Resident #1 towards Resident #2.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. It read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If abuse, neglect, exploitation, or misappropriation of resident property or injury of unknown source is…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-21 · 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 ensure an environment free from risk of accidents and hazards for one (#7) of three residents reviewed for accident hazards out of 15 sample residents. Specifically, the facility failed to ensure staff utilized a mechanical lift, as was care planned, when transferring Resident #7 from her wheelchair to her bed.Findings include: I. Facility policy and procedure The Lifting Machine, Using a Mechanical Lift policy, revised July 2017, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. The policy read in pertinent part, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions.At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.Mechanical lifts may be used for tasks the require lifting a resident from the floor, transferring a resident from bed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-17 · tag F0565 — failed to support the resident council — pattern
    Honor 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 resident interviews, the facility failed to promptly address and attempt to resolve resident group complaints and grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to ensure residents felt their concerns with call light timeliness resulting in long waits for staff assistance were addressed and resolved. Findings include: I. Facility policy and procedure The Resident Council policy, undated, was provided by the nursing home administrator (NHA) on 10/17/24 at 6:04 p.m. The policy read in pertinent part, The purpose of the resident council is to provide a form for: residents families and resident representatives to input in the operation of the facility; discussion of concerns and suggestions for improvement; consensus building and communication between residents and facility staff; and, disseminating information and gathering feedback from interested residents. A resident council response form will be utilized to track issues and their resolutions. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for four of ten resident rooms and one (#6) of two residents reviewed for accidents out of 26 sample residents, received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically the facility failed to: -Ensure tap water in the facility was kept within a safe temperature range; -Initiate a timely fall care plan and interventions to prevent falls for Resident #6; and, -Ensure Resident #6's neurological assessments were completed after the resident sustained an unwitnessed fall in her room on 8/21/24. Findings include: I. Failure to ensure safe water temperatures A. Professional reference According to the Consumer Product Safety Commission (CPSC) Safety Alert, Avoiding Tap Water Scalds, retrieved on 10/23/24 from https://www.cpsc.gov/s3fs-public/5098-Tap-Water-Scalds.pdf, The majority of injuries and deaths involving tap water scalds are 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-17 · 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 resident interviews, staff interviews, and observations, the facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature. Specifically, the facility failed to consistently serve foods at a palatable texture. Findings include: I. Facility policy and procedure The Critical Temperatures for Safe Food Handling policy, undated, was provided by the dietary manager (DM) on 10/17/24 at 5:44 p.m. The policy read in pertinent part, Temperature should be taken periodically to assure hot food stays above 135 degrees Fahrenheit (F) and cold food stays below 41 degrees F during the serving process. Maintain a cold enough holding temperature to assure foods are maintained at or below 41 degrees F until they leave the service area. The Food and Nutrition Services Staff policy, undated, was provided by the DM on 10/17/24 at 6:21 p.m. The policy read in part, Food will be palatable, attractive and served in a timely manner at proper temperatures. II. Resident interviews…

    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 · Ecited before2024-10-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the pantry; and, -Ensure hand hygiene was conducted appropriately. Findings include: I. Failure to store food items appropriately in the the dry storage area A. Professional reference According to the United States Department of Agriculture (USDA) Is Food In Dented Cans Dangerous? (9/18/24) was retrieved on 10/22/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous, food from cans that were leaking, bulging, or badly dented should never be eaten. The damaged cans could contain clostridium botulinum (a toxic bacteria). B. Facility policy and procedure The Food and Nutrition Services Staff policy, undated, was provided by the dietary manager (DM) on 10/17/24 at 6:21 p.m. The policy read in pertinent part, The food service department is staffed by food and nutrition service personnel who have demonstrated the skills…

    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 · Ecited before2024-10-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible developement and transmission of infectious diseases. Specifically, the facility failed to offer COVID-19 vaccinations and provide COVID-19 vaccination information to Resident #28, Resident #12, Resident #5 and Resident #17. Findings include: I. Facility policy and procedure The Coronavirus Disease (COVID-19) - Vaccination of Residents policy, revised May 2023, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part, Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. The resident or resident representative has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision. COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee. Residents are screened for contraindications to the vaccine, medical…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to ensure one (#12) of one of 26 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #12's blood pressure was measured appropriately in accordance with medical standards of practice. Findings include: I. Professional reference How to measure your blood pressure at home fact sheet, dated 2020, was retrieved on 10/21/24 from the American Heart Association medical archives at https://www.heart.org/-/media/Files/Health-Topics/High-Blood-Pressure/measuringbpathome.pdf It documented that the blood pressure cuff should be positioned on the bare arm above the elbow in the middle of the arm. II. Facility policy and procedure The Blood Pressure, Measuring policy, revised September 2010, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part, Expose the resident's arm by rolling the sleeve up about five inches above the elbow. II. Observation On 10/17/24 at 8:42 a.m. registered nurse (RN) #2…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-17 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#15) of three residents reviewed for activities out of 26 sample residents received individualized activities in accordance with standards of care. Specifically, the facility failed to offer Resident #15 activities in Spanish, which was his preferred language. Findings include: I. Resident #15 A. Resident status Resident #15, age greater than 65, was admitted on [DATE] and readmitted [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included kidney failure, bipolar disorder and type 2 diabetes. According to the 7/17/24 minimum data set (MDS) assessment, Resident #15 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent in completing all activities of daily living. According to the 1/15/24 MDS assessment, it was very important for Resident #15 to have books, magazines and newspapers to read., listen to music he liked., do his favorite…

    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
Show the remaining 17 citations
  • Potential for harm · E2024-10-17 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to answer call lights in a timely manner for residents requesting staff assistance. Findings include: I. Facility policy The Staffing policy, revised October 2017, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. The policy read in pertinent part, Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Other support services are also staffed to ensure that resident needs are met. II. Resident council meeting minutes The July 2024 resident council meeting minutes documented call lights were addressed as a concern. According to the meeting minutes, call lights were not always timely. The action item on the meeting minutes, the resident council was informed by the facility that some residents required two staff members for transferring, potentially taking 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents reviewed out of 26 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically, the facility failed to: -Accurately obtain and document Resident #6's weights; and, -Weigh Resident #6 per physician's orders. Findings include: I. Facility policy and procedure The Nutritional Assessment policy, revised October 2017, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part, As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. II. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the October…

    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 · F2023-03-30 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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 provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, the facility failed to educate the dietary staff about the type of dishwasher, the correct temperature and the correct parts per million (PPM). Findings include: I. Professional reference The Colorado Retail Food Establishment Rule and Regulations, revised January 2019 (pg. 24, 113-124, 133-137), read in pertinent part, Cleaning and sanitizing may be done by spray-type, immersion ware washing, or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. Chemical sanitizing ware washing machines (single-tank, stationary-tank, door-type machines and spray-type glass washers) may be used provided that: 1) The temperature of the wash water shall not be less than 120°Fahrenheit (F) (49°Celsius (C)); 2) The wash water shall be kept clean; and 3) Chemicals added for sanitization purposes shall be automatically…

    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 · Fcited before2023-03-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure appropriate hand washing and glove usage in the main kitchen; -Ensure cooked food items were monitored and cooled properly; -Ensure the handwashing sink was only used for handwashing; -Ensure food was labeled, dated and disposed of timely; -Ensure ice pack for human use were not stored with food; and, -Ensure food was cooked to the appropriate temperature. Findings include: I. Ensure appropriate hand washing and glove usage in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. -Ready-to-eat is considered a food without further washing, cooking, or additional preparation and that is…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-03-30 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on four of four units. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene practices; -Ensure appropriate use of personal protective equipment (PPE) such as masks and gloves; and, -Ensure houskeeping staff cleaned resident rooms appropriately. Findings include: I. Facility policy and procedure The Handwashing/Hand Hygiene policy, revised August 2019, was provided by the nursing home administrator (NHA) on 3/30/23 at 2:21 p.m. According to the hand hygiene policy, the facility considered hand hygiene the primary means to prevent the spread of infections. The policy was read in pertinent part: All Personnel should be trained regularly and in-serviced on the importance of hand hygiene 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-30 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to honor resident choices for three (#22, #12 and #15) of four reviewed for self-determination out of 24 sample residents. Specifically, the facility failed to ensure Resident #22, Resident #12 and Resident #15 received showers consistently according to their choice of frequency. Findings include: I. Facility policy and procedure The Personal Care policy and procedure, revised February 2018, was provided by the nursing home administrator (NHA) on 3/30/23 at 2:21 p.m. It revealed in pertinent part, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of resident's skin. Documentation: the date and time the shower was performed, the name and title of the individual(s) who assisted the resident with the shower/tub bath, all assessment data obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath and the signature and title…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-30 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and staff interviews, the facility failed to provide services for seven out of nine sample residents according to professional standards of practice. Specifically, the facility failed to clarify physician's orders with dose information for the administration of diclofenac gel. Findings include: I. Professional reference The diclofenac gel drug information was accessed on 3/29/23 on the Physicians Drug Reference website at https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. Diclofenac is a nonsteroidal anti-inflammatory (NSAID) medication that can be prescribed in intravenous, oral, topical, and ophthalmic formulations. The use of analgesic and antipyretic properties increases the risk of serious gastrio-intestinal events and may increase serious cardiovascular events; use the lowest dose of the shortest time. The topical dosage of diclofenac gel is prescribed as 4 grams (4.5 inches) topically 4 times a daily, with a maximum of 16 grams a day per lower extremity joint) and/or 2 grams (2.25 inches) topically 4 times daily per upper…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0659 — pattern
    Provide care by qualified persons according to each resident's written plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews, the facility failed to ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity which included proper licensure or certification. Specifically, the facility failed to ensure certified nurse aide (CNA) #1, who had medication authority in the facility, was certified in the State registration system to ensure the training was aligned with the requirement of the State. Findings include: I. Review of schedules Review of the working schedules for October 2022, November 2022, December 2022, January 2023, February 2023 and March 2023 identified CNA #1 with medication authority. October 2022: -CNA #1, worked for 10 days: 10/12, 10/11, 10/12, 10/17, 10/18, 10/19, 10/24, 10/25, 10/26 and 10/31/22. November 2022: -CNA #1, worked for 14 days: 11/1, 11/2, 11/7, 118, 11/9, 11/14, 11/15, 11/16, 11/21, 11/22, 11/23, 11/28, 11/29 and 11/30/22. December 2022: -CNA #1, worked for 14 days: 12/2, 12/3, 12/4, 12/9, 12/10, 12/11, 12/16, 12/17, 12/18, 12/23,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-30 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents physical, mental and psychosocial well-being were provided for two (#40 and #22) of three residents reviewed for activities out of 24 sample residents. Specifically, the facility failed to ensure Resident #40 and Resident #22 were provided activities and developed a comprehensive care plan which addressed each resident's socialization and activity needs. Findings include: I. Facility policy and procedure The Group Programs and Activities Calendar policy, revised June 2018, was provided by the nursing home administrator (NHA) on 3/30/23 at 2:21 p.m. It revealed in pertinent part, Group activities are available in this facility and an activities calendar is completed and maintained to inform residents, families, and staff of the activity opportunities available. Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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, resident interview and staff interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for two (#15 and #12) of three residents reviewed for visual problems out of 24 sample residents. Specifically, the facility failed to: -Ensure appropriate follow up on scheduling eye appointments for Resident #15; and, -Ensure Resident #12 was provided with annual eye appointments. Findings include: I. Resident #15 A. Resident status Resident #15, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included other symptoms and signs involving the musculoskeletal system, chronic venous hypertension with ulcer of right lower extremity, type two diabetes mellitus with unspecified complications, other specified depressive episodes, unspecified mood disorder, morbid (severe) obesity with alveolar hyperventilation (out of proportion carbon dioxide production.) The 1/27/23…

    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 · D2023-03-30 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 trauma informed care in order to eliminate or mitigate triggers that caused re-traumatization for one (#11) of two residents reviewed out of 24 sample residents. Specifically, the facility failed identify triggers for Resident #11's post traumatic stress disorder (PTSD) to prevent retraumatization. Findings include: I. Facility policy The Trauma-Informed and Culturally Competent Care policy was received by the nursing home administrator on [DATE]. The policy documented in pertinent part: -Purpose of the policy was to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. -To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Preparation -All staff are provided in-service training about trauma and trauma-informed care in the context of the healthcare setting -Nursing staff are trained on trauma screening and assessment tools; -All…

    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 · D2023-03-30 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to assist a resident in obtaining routine or emergency dental services, as needed for one (#12) out of two residents reviewed for dental services out of 24 sample residents. Specifically, the facility failed to ensure dental services were offered to Resident #12. Findings include: I. Facility policy and procedure The Dental policy and procedure, revised August 2007, was provided by the nursing home administrator (NHA) on 3/30/23 at 2:21 p.m. It revealed in pertinent part, Dental services are available to all residents requiring routine and emergency dental care. Social services will be responsible for making necessary dental appointments. Residents with lost or damaged entures will be promptly referred to a dentist. II. Resident #12 A. Resident status Resident #12, over the age of 90, was admitted on [DATE]. According to the March 2023 computerized physician orders, the diagnoses included adult failure to thrive, anxiety, dementia, glaucoma…

    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 · Fcited before2022-01-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in one of one facility kitchens. Specifically the facility failed to: -Ensure ready-to-eat foods were handled properly; -Store food items and equipment in a sanitary manner; and -Ensure the entire kitchen area was clean and free from dirt, grime and food debris. Findings include I. Facility policy and procedures The Sanitation policy, revised October 2008, was provided by the director of nursing (DON-SF) at a sister facility on 1/6/22 at 2:25 p.m. It documented, The food service area shall be maintained in a clean and sanitary manner. It documented that all kitchens and kitchen areas should be kept clean and free from litter and rubbish. It documented that all utensils, counters, shelves and equipment should be kept clean, maintained in good repair and should be free from breaks or any other issues that may affect their use or proper cleaning. It documented cutting boards, both acrylic or hardwood, would be washed and sanitized between uses. It 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-11 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to honor resident choices regarding bathing frequency and/or type for four (#9, #34, #14 and #37) of six residents reviewed out of 26 sample residents. Specifically, the facility failed to honor the Resident #9, #34, #14 and #37's bathing preferences. The residents all said they did not receive baths/showers frequently enough and according to their preferences. Findings include: I. Facility policy The Supporting Activities of Daily Living (ADLs) policy, revised March 2018, provided by the corporate clinical consultant on 1/11/22 at 2:40 p.m., included: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with bathing. II. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-11 · 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 observations, interviews and record review, the facility failed to provide palatable foods to seven of seven (#21, #23, #34, #18, #9, #10 and #32) residents interviewed for palatability out of 26 sample residents. Specifically, the facility failed to ensure proper temperatures of food served to the residents, which made the meals unpalatable to them. The residents also complained about availability of certain food items, especially breakfast meats, juices and ice cream. Findings include: I. Facility policy and procedure The Dining Experience policy, dated 2019, was provided by the nursing home administrator (NHA) on 1/11/22 at 12:06 p.m. It documented the dining experience would be person-centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. It documented residents would be provided with nourishing, palatable, attractive meals that meet daily nutritional needs and food preferences and are served at a safe and appetizing temperature. The Dining Experience: Staff Responsibility policy, dated…

    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 · D2022-01-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 (#5) of two residents reviewed out of 26 sample residents received restorative services to ensure the highest practicable physical well-being. Specifically, the facility failed to provide restorative services for Resident #5 after she was discharged from therapy. Resident #5's goal was to improve and maintain her independence so she could discharge back to her home in the community, but she said her physical function had declined. The facility failed to provide a restorative program to provide services to Resident #5. Findings include: I. Facility policy The Restorative Nursing Services policy, revised July 2017, provided by the corporate clinical consultant on the afternoon of 1/11/22, documented in pertinent part: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized…

    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 · D2022-01-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide catheter care for one (#34) of six residents reviewed out of 26 sample residents. Specifically, nursing staff failed to consistently provide and document Resident #34's suprapubic catheter care every shift with soap and water per physician orders and professional standards. The facility further failed to assess and document the condition of the resident's suprapubic catheter site, which had redness and drainage. Findings include: I. Facility policy and procedures The Urinary Catheter Care policy, revised September 2014, provided on the afternoon of 1/11/22 by the corporate clinical consultant (CCC), included: The purpose of this procedure is to prevent catheter-associated urinary tract infections (UTIs). -Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. -Do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place. Routine…

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

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

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$5,293 in federal fines across 1 penalty.

  • $5,293 — penalty dated 2023-09-05

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 MADISON CREEK PARTNERS — 13 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 →

RatingThis homeChain avg
Overall 2 of 53.2-1.2 vs chain
Health inspection 3 of 53.0≈ chain avg
Staffing 1 of 53.3-2.3 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 12 homes this chain runs (chain average 3.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
CHIEF JOSEPH TRAIL, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/02/2026
TIPPET, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST83%since 03/02/2026
WHITE CANYON, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST18%since 03/02/2026
CLEGG, MICHAELIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/1974
IKERD, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/02/2026
MADISON CREEK PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/25/2026
ADRAGNA, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/25/2019
CHRISTENSEN, COVEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2016
FRIIS, LARRYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/19/2026
HOPKINS, AMBERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021

CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$6.4M
Net patient revenuemost recent cost report
+2.8%
Operating marginrevenue minus expenses
$748K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 23%Other / private 17%

This home reported $748K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$412per resident / day
operating cost
$12,528per month
≈ monthly operating cost
$424per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Colorado
$10,159/mo
Nursing home (semi-private)
$12,182/mo
Nursing home (private)
$6,584/mo
Assisted living

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 065244. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-17, 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.

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