La Villa Grande Care Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

43.7% 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: 55.0% 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 40 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 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 96 beds and averages 82.2 residents a day — about 86% occupied, or roughly 14 beds typically open. It runs fairly full. 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 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 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 2.76 hrs/resident/day on weekends vs 3.44 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.89 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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

Inspection deficiencies

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

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

32 citations, most serious first. The 14 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · J2025-12-18 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to prevent a significant medication error for warfarin (a blood thinner medication) for one (#8) of three residents reviewed for medication errors out of 10 sample residents.Specifically, the facility failed to prevent a significant medication error when Resident #8 received warfarin, a blood-thinning medication, twice a day (once in the morning and once in the evening), instead of once a day at bedtime.Resident #8 was admitted on [DATE] and discharged to home on 9/22/25. Resident #8's diagnoses included hypertension, kidney disease, diabetes, stroke, and left-sided paralysis. Resident #8 was admitted to the facility from the hospital with stroke treatment and prevention orders for warfarin and laboratory monitoring of the blood level international normalized ratio (INR), which is used to monitor the ability for blood to clot. Resident #8's admitting physician's orders on 8/25/25 included testing of the INR on 8/26/25 and warfarin 1 milligram (mg) in the…

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

  Pharmacy Service Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2025-05-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#28) of three residents out of 37 sample residents. Resident #28, who was at risk for falls, was admitted on [DATE] with diagnoses of dementia, history of falling, abnormalities of gait and mobility, weakness and insomnia. On 5/1/25 the physician recommended the resident transition to a walker without wheels for safety and have a physical therapy (PT) evaluation. However, Resident #28 continued to use her four-wheel walker and a PT evaluation was not conducted until 5/13/25. Resident #28 fell three times in less than a week (on 5/6/25, 5/9/25 and 5/10/25). She was identified to have high blood pressure after the falls and was discovered to have a urinary tract infection (UTI) after the last fall on 5/10/25, increasing her risk for falls. All three of the falls occurred in the early morning hours when Resident #28 got out of bed independently. However, 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
• Actual harm · G2023-11-16 · 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 ensure one resident (#83) of five sample residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable, and to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the facility failed to ensure timely interventions were put in place to prevent the development of pressure injuries to Resident #83's heels which resulted in two unstageable pressure injuries. Resident #83 was admitted to the facility after a fall resulting in her impaired mobility. The resident was at risk for pressure injuries and had a current pressure injury to her sacrum on admission. The resident developed a stage II pressure injury to her right heel and a deep tissue pressure injury to her left heel in less than a week after her admission. The pressure injuries were not…

  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 before2022-08-11 · 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 effective and timely fall prevention practices to prevent falls for two (#19 and #49) of 12 residents out of 30 sample residents. Specifically, the facility failed to: -Conduct timely post fall investigations or at all; -Review residents' falls with the interdisciplinary team (IDT); -Update residents' care plans to reflect interventions to prevent falls; -Educate new staff on fall preventions for residents; and, -Follow care planned interventions to prevent falls. These failures led Resident #19 to experience six falls since admission from 2/2/22 through 7/18/22, the date of last fall, which resulted in the resident being treated at the emergency room for excessive bleeding of a head wound sustained during the fall requiring the resident to receive six staples to his head to close the wound. These failure also led Resident #49 to experience eight falls since admission from 3/7/22 through 7/9/22, the date of last fall. Early…

  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 · E2025-05-22 · tag F0605 — failed to not use drugs as a restraint — pattern
  Prevent 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 VI. Resident #387 A. Resident status Resident #387, age over 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included stage three chronic kidney disease and bipolar disorder. The 7/4/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required partial to moderate assistance with toileting, personal hygiene, bathing and lower body dressing. B. Record review A review of Resident #387's May 2025 CPO revealed the following physician's orders: Olanzapine (Zyprexa, an antipsychotic medication) oral tablet 5 mg, give 2.5 mg (half tablet) by mouth as needed (PRN) for agitation daily at night, ordered 5/17/25 with an end date of 5/31/25. Lorazepam (an antianxiety medication) oral tablet 0.5 mg, give one tablet by mouth daily PRN for anxiety, ordered 5//25 with an end date of 5/31/25. Lamotrigine oral tablet give 50 mg by mouth one time a day related to bipolar disorder, ordered 5/18/25. Monitor resident's behaviors, such as rapid mood…

  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 · E2025-05-22 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in temperature and taste. Findings include: I. Facility policy and procedure The Assistance with Meal policy, revised March 2022, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. The policy read in pertinent part, Hot food shall be held at a temperature of 135 degrees or above until served. Cold food shall be held at 41 degrees or below until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement. II. Resident interviews Resident #53 was interviewed on 5/19/25 at 11:02 a.m. She said the food could taste better. Resident #58 was interviewed on 5/19/25 at 11:38 a.m. He said about three times a week the hot food was not hot or warm. Resident #44 was interviewed on 5/19/25 at 5:47 p.m. He said meat at the facility was always too dry and did not…

  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 before2025-05-22 · 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

  II. Failure to use consistent hand hygiene practices when providing meal assistance A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Handwashing Facts dated 4/17/24, retrieved on 6/1/25 from https://www.cdc.gov/clean-hands/data-research/facts-stats/index.html, Hand washing with soap removes germs from hands. This helps prevent infections because people frequently touch their eyes, nose and mouth without even realizing it. Germs get into the body through the eyes, nose and mouth and make us sick. Germs from unwashed hands can get into food and drinks while people prepare or consume it. Germs can multiply and some types of foods or drinks, under certain conditions and make people sick. Germs from unwashed hands could be transferred to other objects and then transferred to another person's hands. B. Facility policy and procedure The Handwashing/Hand Hygiene policy, dated 2001, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:45 p.m. The policy read in part, This facility considers hand hygiene the primary means to prevent…

  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 · D2025-05-22 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#15) of one resident out of 37 sample residents. Specifically, the facility failed to ensure an assessment was conducted to determine whether the self-administration of medications was clinically appropriate for Resident #15. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy and procedure, revised February 2021, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. It revealed in pertinent part, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. 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 · D2025-05-22 · tag F0574 — isolated
  The resident has the right to receive notices in a format and a language he or she understands.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to ensure the State Survey Agency (SSA) contact information, including the phone number, address and email address were posted and in a manner accessible and understandable to all residents. Findings include: I. Resident group interview A group interview was conducted on 5/21/25 at 10:00 a.m. with five residents (#14, #52, #64, #66 and #77) who were deemed interviewable through the facility and assessment. All five of the residents said they were not aware they could contact the SA and did not know where to get the SA's contact information. II. Observations On 5/21/25 at 9:50 a.m., a walk-through of the facility was conducted and did not reveal a posting for the SA's contact information, to include the agency's phone number, address and email address. III. Staff interview The nursing home administrator (NHA) was interviewed on 5/21/25 at 11:15 a.m. The NHA confirmed 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 · D2025-05-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#68 and #71) of seven residents out of 37 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent an altercation between Resident #68 and Resident #71; -Protect Resident #68 from physical abuse by Resident #65; and, -Protect Resident #71 from physical abuse by Resident #68. Findings include: I. Facility policy and procedure The Abuse, Neglect, exploitation or misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. The policy read in pertinent part, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. II. Altercation between Resident #68 and Resident #71 on 2/14/25 A. Facility investigation The facility investigation…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-22 · 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 observations, record review and interviews, the facility failed to ensure one (#80) of two residents with limited range of motion out of 37 sample residents received appropriate treatment and services. Specifically, the facility failed to ensure Resident #80 was consistently provided services through the walk-to-dine program in order to maintain the resident's ambulation status. Findings include: I. Facility policy and procedure The Restorative Nursing Services policy, revised July 2017 was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. It revealed 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 rehabilitative services (physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-22 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility's medication error rate was 7.69%, which was two errors out of 26 opportunities for error. Findings include: I. Medication administration observations On 5/21/25 at 9:35 a.m. registered nurse (RN) #3 was preparing and administering medications for Resident #15. Resident #15 had physician's orders for the following medications: Carboxymethylcellulose-Glycerin ophthalmic gel 1-0.9 % (Genteal moisturizing gel), instill one drop to each eye twice a day for dry eyes, ordered 5/14/24. -However, RN #3 administered Hypromellose/Dextran/Glycerin ophthalmic eye drops (Genteal moisturizing eye drops) to Resident #15 instead of the Genteal moisturizing gel specified in the physician's order. Calcium Carbonate chewable tablet 500 milligrams (mg), give one tablet by mouth three times a day, ordered 3/7/24. RN #3 attempted to administer a Calcium Carbonate chewable tablet 500 mg as ordered by the physician to Resident #15. 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-10-08 · 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, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the refrigerators and pantry; and, -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination. Findings include: I. Failure to store food items appropriately in the refrigerators and the dry storage area A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/16/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices and sugar shall be identified with the common name of the food. In a mechanically refrigerated or…

  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 · D2024-10-08 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure services provided met professional standards of practice for two (#3 and #9) of seven residents out of 5 sample residents. Specifically, the facility failed to: -Ensure Resident #9's fluid intake was monitored and managed effectively, which resulted in the resident being sent to the hospital for fluid overload; -Provide Resident #3, who chose not to consistently follow her recommended diabetic diet, with education related to the specific risks associated with not following her dietary recommendations; and, -Ensure Resident #3's diabetic care plan was updated to include documentation of the resident's refusals to comply with her recommended diabetic diet. Findings include: I. Professional standards According to the National Institutes of Health Library of Medicine: Interventions For Improving Adherence To Dietary Salt and Fluid Restrictions In People With Chronic Kidney Disease Stage 4 and 5, retrieved on 10/9/24 from…

  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

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

Fines & penalties

$89,269 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $31,736 — penalty dated 2025-05-22
• $4,545 — penalty dated 2024-01-02
• $11,538 — penalty dated 2023-12-11
• $32,981 — penalty dated 2023-11-16
• $8,469 — penalty dated 2023-09-11
• Medicare payment denial — starting 2023-12-16 for 10 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to STELLAR SENIOR LIVING — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 48 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.

15 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.

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