Brookdale Greenwood Village
6450 S Boston St, Greenwood Village, CO 80111 · For profit - Limited Liability company · 90 certified beds · (303) 224-9455 Medicare only — no Medicaid
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- it has 2 actual-harm citations
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $32,700 in federal fines (most recent 2026-04-09)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.1% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.1% | 4.7% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 1.4% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.0% | 8.8% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.4% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 0.0% | 11.5% | 18.9% | check this* — see note marked star below the table |
| Long-stay residents given the seasonal flu vaccine | 83.3% | 94.7% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.0% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 20.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 55.5% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.1% | 20.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.8% | 12.1% | 12.0% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
48.1% 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 237 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.0% 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 100 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 0.63 therapist hours per resident per day in 2026Q1 — more than 89% 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.1%CMS range 41.9–55.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.8–13.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 91.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 4.0–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 52.3 residents a day — about 58% occupied, or roughly 38 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.22 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.78 hrs/resident/day on weekends vs 4.52 on weekdays — 16% thinner on weekends. RN hours go from 1.41 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2026-04-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 prevent and treat pressure injuries for one (#20) of two residents out of 34 sample residents.Resident #20, who was dependent on staff for all care and mobility and was known to be at risk for skin breakdown, was admitted to the facility on [DATE] with a right hip surgical incision, but did not have any pressure injuries. The facility did not implement interventions to offload the resident's heels or provide a low-air loss mattress upon the resident's admission to the facility.Additionally, the facility failed to conduct a Braden Scale assessment (a tool utilized for predicting pressure ulcer injury risk) upon the resident's admission to the facility.On 4/6/26, seventeen days after the resident's admission to the facility, Resident #20 developed a stage 3 pressure injury to her right heel. Following the development of Resident #20's right heel pressure injury, the facility implemented an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2026-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#28) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure supervision was provided, as determined in an assessment, to prevent a fall for Resident #28 that resulted in fractures. Resident #28 was admitted on [DATE] with diagnoses of sepsis (infection of the blood), unsteadiness on feet, generalized muscle weakness, repeated falls and other Alzheimer's disease.Resident #28, was identified as a fall risk and had a history of repeated falls. Resident #28 was found outside by facility staff on 3/29/26. Resident #28 was bleeding from her mouth and had pain when trying to bend her knees. Resident #28 was sent to the emergency department, where it was determined that Resident #28 had sustained a fracture to her coccyx and facial bones. Resident #28 did not return to the facility. Findings include:I. Facility policy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 accordance with professional standards for food service safety in two of two kitchenettes. Specifically, the facility failed to ensure staff used proper hand hygiene during meal service. Findings include: I. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/16/26. It revealed in pertinent part, The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, 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.
- Potential for harm · E2026-04-09 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to complete grievance forms consistently to address and promptly resolve resident grievances.Specifically, the facility failed to effectively address, resolve, and demonstrate the facility's response to group grievances. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, reviewed March 2018, was provided by the nursing home administrator (NHA) on 4/6/2 at 9:00 a.m. It revealed in pertinent part, A resident, his/her representative, family member, visitor or advocate may file a verbal or written comment, grievance or complaint concerning resident rights, treatment, abuse, neglect, harassment, medical care, behavior of other residents, theft of property without fear of threat or reprisal in any manner. Such grievances or complaints may be made anonymously. For a written grievance or complaint, complete an accurate and detailed complaint/grievance form located at the nurse's station or community designated area. Return the completed complaint/grievance form to the administrator, who is the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections on two of two units.Specifically, the facility failed to:-Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP);-Ensure an effective process was in place to ensure staff were aware of which residents were on EBP; and,-Ensure nursing staff cleaned blood pressure cuffs between residents. Findings include: I. EBP failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 4/9/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part, Enhanced barrier…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-09 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 consent was obtained for the use of psychotropic medications for one (#4) of five residents reviewed for unnecessary medications out of 34 sample residents. Specifically, the facility failed to ensure informed consents, which included risks versus benefits and side effects of prescribed psychotropic medications. Findings include:I. Facility policy and procedureThe Psychotropic Drug Management policy, revised March 2026, was provided by the nursing home administrator (NHA) on 4/13/26 at 11:07 a.m. It read in pertinent part, Nursing shall not administer the psychotropic medication until informed consent has been obtained from the resident and/or legal representative, except in emergency situations. Informed consent should be obtained from the resident and/or legal resident representative for increase in dose, or PRN (as needed) extension with documented rationale or re-evaluation as indicated.II. Resident #4A. Resident statusResident #4, age…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in one of five medication carts.Specifically, the facility failed to ensure expired and discontinued medications were removed from the medication cart and disposed of. Findings include:I. ObservationsOn [DATE] at 11:23 a.m. The second floor north medication cart was observed with licensed practical nurse (LPN) #3 and contained the following:The drawer on the medication cart for Resident #29 contained the following: Hydrocodone/acetaminophen (pain medication) oral tablet 5 milligram (mg)/325 mg. The order was on [DATE]. The drawer on the medication cart for Resident #22 contained the following: Hydromorphone (pain medication) oral tablet 2 mg. The order was discontinued on [DATE]. The drawer on the medication cart for over the counter medications contained the following: An opened bottle of senna (laxative) oral tablet 8.6 mg that did not have an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-09 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to meet all requirements for the provision of hospice are for one (#7) of one resident reviewed for hospice out of 34 sample residents. Specifically, the facility failed to demonstrate adequate communication with the hospice staff and facility staff regarding care that the hospice staff provided during visits. Findings include: I. Facility policy and procedureThe Hospice Care policy and procedure, revised October 2016, was provided by the nursing home administrator (NHA) on 4/6/26 at 12:47 p.m. It read in pertinent part, Hospice progress notes shall be included in the resident's medical record and nursing associates shall be informed of any changes recommended by the hospice staff.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included dementia, acute kidney failure, and acute chronic respiratory failure with hypoxia (lungs cannot adequately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#6 and #30) of five residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to:-Ensure Resident #6 received the pneumococcal vaccine when consent was given; and,-Ensure Resident #30 was offered the flu vaccine. Findings include:I. Professional Reference According to the Centers for Disease Control and Preventions (CDC) Flu, revised 9/5/24 and retrieved 4/14/26 from https://www.cdc.gov/flu/highrisk/65over.htm, Flu vaccination is especially important for people 65 years and older because they are at higher risk of developing serious flu complications. While flu seasons vary in severity, during most seasons, people 65 years and older bear the greatest burden of severe flu disease. CDC and the Advisory Committee on Immunization Practices (ACIP) preferentially recommend the use of higher dose flu vaccines (including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-09 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 develop and implement policies and procedures related to immunizations for two (#2 and #7) of five residents reviewed for immunizations out of 34 sample residents.Specifically, the facility failed to:-Ensure the COVID-19 vaccine was provided to Resident #2 after she received education and gave consent; and,-Ensure Resident #7's medical record documented if the resident was offered the COVID-19 vaccine when available and documentation documented if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Findings include:I. Professional referenceAccording to the Centers for Disease Control's (CDC) Staying Up to Date with COVID-19 Vaccines, updated 11/19/25, retrieved on 4/14/26 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, read in pertinent part, Getting the 2025-2026 COVID-19 vaccine is important because:-Protection from the COVID-19 vaccine decreases with time;-Immunity after COVID-19 infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 ensure that food was stored, prepared, distributed, and served in accordance with professional food safety standards in the main kitchenSpecifically, the facility failed to ensure:-The kitchen was kept in a sanitary manner;-Perishable foods were properly labeled, stored, and maintained; and, -The ice machine was maintained in a sanitary condition. Findings include:I. Failure to ensure the kitchen was kept in a sanitary mannerA. Professional referenceAccording to the U.S. Food and Drug Administration Food Code (Effective 2022) retrieved on 10/1/25, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. (3-178) After cleaning and sanitizing, equipment and utensils: Shall be air-dried or used after adequate draining before contact with food. (chapter 4) Physical facilities shall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#2) of three residents received the highest practicable treatment and care in accordance with professional standards of practice of seven sample residents.Specifically, the facility failed to ensure all prescribed medications including medications to treat cirrhosis of the liver (scarred and damaged liver that prevents it from working properly), high blood pressure, and a chronic mental health disorder were ordered and obtained from the pharmacy to administer to the resident upon admission. Findings include:I. Facility policy and procedureThe admission Process policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 9/22/25 at 11:31 a.m. The policy read in pertinent part, Admissions will follow a process so that the community can appropriately meet the clinical and financial needs of residents. Once the community gives verbal acceptance of a resident, the admission Department will notify 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.
Show the remaining 20 citations
- Potential for harm · Dcited before2025-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#2) of three residents reviewed for accident hazards/ falls out of seven sample residents.Specifically, the facility failed to:-Ensure Resident #2, who had a history of falls, was appropriately assessed at admission to determine needed interventions to prevent ongoing falls; -Ensure appropriate fall prevention interventions were in place; and,-Ensure all clinical staff were educated on Resident #2's orthostatic hypotension diagnosis (a sudden drop in blood pressure that happens when a resident changes position from lying or seated position to a standing position causes dizziness and/or fainting) which puts the resident at a high risk for falls. Findings include:I. Professional referenceAccording to [NAME] M, [NAME] A, Taraborrelli P, Panagopolous D, Torocastro M, [NAME] R, Lim PB. Orthostatic Hypotension in Older People: Considerations, Diagnosis and Management, 3/21/21. Retrieved…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#1 and #4) of three residents who required respiratory care received care consistent with professional standards of practice out of seven sample residents.Specifically, the facility failed to:-Ensure Resident #1 and Resident #4 were provided their physician-ordered continuous positive airway pressure (CPAP) treatment consistently; and, -Ensure Resident #4's CPAP machine was cleaned and stored properly. Findings include:I. Facility policy and procedureThe admission Data Collection and Orders policy, revised September 2025, was provided by the director of nursing (DON) on 9/23/25. It read in pertinent part, The charge nurse who admits the resident is responsible for completing the nursing admission data collection, verifying orders are present for admission, additional corresponding data collections, and reviewing the information sent by the discharging community, hospital, and/or attending physician.The CPAP/BiPAP (bilevel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-28 · tag F0810 — patternProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 accessible dining equipment and utensils for residents who need them for three (#22, #18, and #1) of three residents reviewed for adaptive equipment out of 35 sample residents. Specifically, the facility failed to: -Provide adaptive drinking equipment for Resident #22 and Resident #18; and, -Provide plate guards for Resident #1. Findings include: I. Facility policy The Adaptive Equipment policy, revised May 2010, was received from the director of nursing (DON) on 3/28/24 at 6:01 p.m. It read in pertinent part: The Dining Services Management should ensure residents who require adaptive equipment to enhance independence and/or support habilitation during dining will be provided equipment. II. Resident #22 A. Resident status Resident #22, age [AGE], was admitted to the facility on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included dysphagia and Alzheimer's disease. The 3/5/24 minimum data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two satellite kitchens. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely; and -Ensure ready to eat foods were handled appropriately. Findings include: I. Food was labeled and dated and disposed of timely A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 4/9//24 from:https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-28 · tag F0880 — failed to prevent and control infections — patternProvide 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 record review, observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections on two of two units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned from cleaner to dirtier areas; -Ensure housekeeping changed gloves and performed hand hygiene between cleaning the bathroom and bedroom; -Provide accurate isolation precaution and appropriate use of personal protective equipment (PPE); -Ensure staff performed hand hygiene; -Ensure residents were offered hand hygiene prior to eating; and, -Follow the water management plan I. Housekeeping failures A. Professional reference According to The Centers for Disease Control (CDC) Environment Cleaning Procedures, (5/4/23), retrieved on 4/9/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, Proceed From Cleaner To Dirtier Proceed from cleaner to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 record review and interviews, the facility failed to offer choices to residents for two (#1 and #23) of three residents reviewed for activities of daily living (ADL) out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and #23 received showers consistently according to their choice of frequency. Findings include: I. Record review The 3rd floor shower schedule was obtained from certified nurse aide (CNA) #3 on 3/28/24 at 1:22 p.m. It documented odd numbered rooms' residents were to receive showers on day shift and even numbered rooms' residents were to receive showers on the night shift. It documented specific days each room number would be showered. According to the shower schedule, Resident #1's room was to receive showers on Tuesdays and Fridays and Resident #23's room was to receive showers on Wednesdays and Saturdays. II. Resident #1 A. Resident Status Resident #1, over the age of 65, was admitted on [DATE]. According to the March 2024 computerized physician order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for two (#49 and #23) of four residents reviewed for services to maintain highest practicable quality of life out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #49 received assistance for nail care; and, -Ensure Resident #23 received assistance to maintain oral hygiene. Findings include: I. Facility policy and procedure The Oral Health Care and Dental services policy, dated November 2017, was received from the director of nursing (DON) on 3/28/24 at 5:41 p.m. It documented in pertinent part, Nursing associates will conduct oral health assessments on admission and at least quarterly to assure that each resident receives adequate oral hygiene. -The nail care policy was requested but was not received by the end of the survey. II. Resident #49 A. Resident status Resident #49, age [AGE], was admitted on [DATE]. According to the March 2024 computerized…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#47 and #16) of three residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the failed to: -Assess and document Resident #47's blood pressure and heart rate consistently prior to administering blood pressure medications; and, -Obtain weights according to the physician's orders for Resident #16. Findings include: I. Resident #47 A. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK532906 on 4/1/24. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockage of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 (#49 and #16) of four residents reviewed for ancillary services out of 35 sample residents received proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure foot care was provided for Resident #49 and Resident #16. Findings include: I. Facility policy and procedure The foot care policy was requested on 3/28/24 at 6:01p.m. however it was not received. II. Resident #49 A. Resident status Resident #49, age [AGE], was admitted to the facility on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included alcohol abuse and adult failure to thrive. The 2/6/24 minimum data assessment (MDS) assessment showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required partial to moderate assistance with all activities of daily living. -The CPO did not reveal any diagnoses of diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for two (#6 and #41) of three residents out of 35 residents Specifically, the facility failed to ensure Resident #6 and Resident #41, who were both at risk for falls, had their beds in the lowest position when the residents were in bed. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E. [NAME], St. Louis Missouri, pp. 2016, retrieved on 4/1/24, Patient safety is your priority, so although you should raise the bed for a comfortable working level, be sure to place the resident's bed in the lowest position before leaving the bedside. II. Facility policy The Falls Management policy was obtained from the director of nursing (DON) on 3/27/24 at 5:41 p.m. It documented in pertinent part, Residents have the potential to fall and therefore the facility has identified universal fall precautions for 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.
- Potential for harm · D2024-03-28 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and observations, the facility failed to provide an effective pain management regime in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#216) out of 35 sample residents. Specifically, the facility failed to: -Ensure a pain assessment was completed that identified the onset, the presence and duration of pain for Resident #216; -Ensure to identify the resident's goal for pain management and acceptable level of pain for Resident #216; -Ensure to identify a new pain location for Resident #216; and, -Ensure to monitor the effectiveness of the pain medication for Resident #216. Findings include: I. Facility policy and procedure The Pain Management policy, effective March 2021, was received by the director of nursing (DON) on 3/28/24 at 6:01 p.m. It read in pertinent part: The onset or complaint of unrelieved pain should be documented in the resident record. Interventions for pain management should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 observations, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#265) of four residents reviewed for medication errors out of 35 sample residents. Specifically, the facility failed to follow physician ordered parameters for medication administration for Resident #265's midodrine (a medication used to treat low blood pressure). Findings include: I. Manufacturer's guidelines The midodrine hydrochloride manufacturer's guidelines, dated July 9th 2020, were obtained from the National Institute of Health (NIH) Library of Medicine database on 3/29/24. It documented in pertinent part: Warnings: Supine hypertension (elevated blood pressure when lying down): The most potentially serious adverse reaction associated with midodrine therapy is marked elevation of supine arterial blood pressure (supine hypertension). II. Facility Policy The Physician/Prescriber Authorization and Communication of Orders to Pharmacy policy, dated 2013, was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards on two of 6 medication carts. Specifically, the facility failed to ensure medication carts were locked appropriately when they were unattended. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 1976, retrieved on 4/1/24, All drugs are secured in designated areas only accessible to nurses. II. Facility Policy The Storage and Expiration of Medications, Biologicals, Syringes, and Needles policy was obtained from the nursing home administrator (NHA) on 3/27/24 at 11:14 a.m. It read in pertinent part, The facility should ensure that only authorized facility staff should have possession of keys, access cards, electronic codes, or combinations which open medication storage areas. The facility should ensure that all medications and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents maintained adequate hydration for two (#31 and #266) of two residents reviewed for hydration out of 35 sample residents. Specifically, the facility failed to: -Encourage fluid intake for Resident #31; and, -Provide thickened liquids per physician's orders for Resident #31 and Resident #266. Findings include: I. Facility policy The Thickened Liquids policy, revised May 2020, was received from the director of nursing (DON) on 3/28/24 at 6:01p.m. It reads in pertinent part: The purpose of this policy is to provide appropriate food and fluid for residents with health care provider diet orders for thickened liquids to provide adequate hydration and to diminish risk of aspiration. (Charge nurse roles and responsibilities include) collaborate with the Registered Dietician (RD) as needed and communicate diet restrictions to Certified Nursing Assistants (CNA). The Resident Hydration and Prevention of Dehydration policy, revised…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 implement policies and procedures related to pneumococcal immunizations for one (#6) of five residents reviewed for immunizations out of 35 sample residents. Specifically, the facility failed to administer the pneumococcal vaccination after consent was provided for Resident #6. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2024, retrieved on 4/4/24, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, Routine vaccination-pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for one of two resident rooms. Specifically, the facility failed to wear appropriate personal protective equipment (PPE) in a resident room was symptomatic and positive for influenza. Findings include: I. Professional reference According to the Center for Disease Control (CDC), Prevention Strategies for Seasonal Influenza in Healthcare Settings retrieved on 1/30/24 from: https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm (reviewed 5/13/21) revealed in pertinent part, Adhere to droplet precautions: droplet precautions should be implemented for patients with suspected or confirmed influenza for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility. II. Facility policy and procedure The Isolation Precautions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-21 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 observations, interviews, and record review, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for two (#164 and #33) out of five residents reviewed for bathing preferences out of 26 sample residents. Specifically, the facility failed to provide consistent showers for Resident #164 and Resident #33 according to their preferences and routine shower schedules. Findings include: I. Facility policy The Supporting Activities of Daily Living policy, dated March 2018, was provided by the director of nursing (DON) on 12/21/22 at 1:30 p.m. It revealed in pertinent part: Residents should be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Appropriate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 (#55) of two residents reviewed for pressure injuries received care and services, consistent with professional standards of practice, to prevent development and promote healing of pressure injuries, out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #55's Prevalon (offloading) boots were in place; and, -Implement interventions (Prevalon boots and air mattress) to Resident #55's care plan to promote wound healing. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 1/4/23, pressure ulcer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-21 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed ensure ongoing assessment of the resident's condition by monitoring for complications before and after dialysis treatments for one (#60) out of one resident reviewed for hemodialysis of 26 sample residents. Specifically, the facility failed to ensure for Resident #60: -The facility received ongoing communication and collaboration with the dialysis facility regarding the dialysis care and services; -Facility staff completed the pre and post dialysis communication forms for seven out of eleven dialysis treatments; -Documentation in the medical record was consistent with pre and post dialysis condition and weight measurements; and, -Evaluate the resident's response to the dialysis session. Findings include: I. Facility policy The Dialysis Care policy, revised December 2015, was provided by the director of nurses (DON) on 12/21/22 at 1:30 p.m. The policy read in pertinent part, provide nursing care that maintains the patency of arteriovenous…
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.
- No harm found · C2024-03-28 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Findings include: I. Failure to have staffing posted Observations in the facility on 3/26/24 at 4:01 p.m. revealed no nurse staff posting. On the third floor there was a binder that said staffing information. The binder said for only facility staff and agency staff were able to open the binder. The director of nursing (DON) was interviewed on 3/28/24 at 10:07 a.m. The DON said the staffing was typically posted at the nurses station or on a board near the nurses station. The DON said the nursing schedule was in a binder located behind the nurses station on the second floor unit. The DON said the nursing schedule was in a binder at the nurses station on the third floor unit. The DON said she was unsure why there was a sign on 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$32,700 in federal fines across 2 penalties.
- $16,350 — penalty dated 2026-04-09
- $16,350 — penalty dated 2026-04-09
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 BROOKDALE SENIOR LIVING — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 4.1 | ≈ chain avg |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 11 homes this chain runs (chain average 3.5★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| ALLY BANK | Organization | 5% OR GREATER SECURITY INTEREST | since 02/09/2024 |
| LEISURE, RAYMOND | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| STENGLE, NIKOLAS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 11/08/2025 |
| WHITE, CHADWICK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/09/2018 |
| KUSSOW, DAWN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/15/2024 |
| LA MARRE, KEVIN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/22/2017 |
| MUNOZ, ANNA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 02/15/2024 |
| DAMASK, JEANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/22/2025 |
| HOUSTON, TABETHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/22/2025 |
| REDDY, VIKAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/22/2025 |
| VINING, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/22/2025 |
| ALLY FINANCIAL INC | Organization | ADP OF THE SNF | since 10/02/2025 |
| AMERICAN RETIREMENT CORPORATION | Organization | ADP OF THE SNF | since 02/15/1998 |
| ARC GREENWOOD VILLAGE INC | Organization | ADP OF THE SNF | since 10/05/2006 |
| BROOKDALE SENIOR LIVING INC | Organization | ADP OF THE SNF | since 07/25/2006 |
| IB FINANCE HOLDING COMPANY LLC | Organization | ADP OF THE SNF | since 10/02/2025 |
| LBMC PC | Organization | ADP OF THE SNF | since 01/01/2024 |
| WALTERS FINANCIAL SERVICES INC | Organization | ADP OF THE SNF | since 07/22/2025 |
| ASHER, JORDAN | Individual | ADP OF THE SNF | since 02/24/2020 |
| DRAYTON, CLAUDIA | Individual | ADP OF THE SNF | since 06/18/2024 |
| FIORAVANTI, MARK | Individual | ADP OF THE SNF | since 04/13/2025 |
| FREED, VICTORIA | Individual | ADP OF THE SNF | since 10/29/2019 |
| HAUSMAN, JOSHUA | Individual | ADP OF THE SNF | since 04/24/2025 |
| KADARI, RAJENDRA | Individual | ADP OF THE SNF | since 09/26/2025 |
| MACE, ELIZABETH | Individual | ADP OF THE SNF | since 06/18/2024 |
| WARREN, DENISE | Individual | ADP OF THE SNF | since 10/04/2018 |
| WIELANSKY, LEE | Individual | ADP OF THE SNF | since 04/23/2015 |
CMS files one row per role, so the 42 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent 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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Colorado Medicaid page for homes that do.
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 065376. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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.