Lakewood Villa

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 57 beds and averages 53.9 residents a day — about 95% occupied, or roughly 3 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.91 hrs/resident/day on weekends vs 3.18 on weekdays — 9% thinner on weekends. RN hours go from 0.66 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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.

21 citations, most serious first. The 15 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-05-01 · 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, interviews, and record review, the facility failed to ensure two (#1 and #2) out of five sample residents at risk for elopement, received adequate supervision and facility assistive devices to prevent elopement. Specifically, the facility failed to provide Resident #1 and Resident #2 the supervision necessary to prevent elopements. These facility failures created a situation with serious harm and a situation with the likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), unsteadiness on feet, restlessness and agitation and need for supervision, eloped from the facility on 12/24/23 at approximately 10:11 p.m. when he exited the facility through an alarmed dining room door and an outside gate which was unlocked. Facility staff…

  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 · Past Non-Compliance
• Actual harm · Gcited before2023-07-17 · 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 III. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included vascular dementia moderate with other behavioral disturbance, other lack of coordination, wandering in disease classified elsewhere, suicidal ideations and macular degeneration (deterioration of the eye). The 6/1/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of seven out of 15. He required limited assistance of one person for bed mobility, transfers and walking in his room. He required extensive assistance of one person for walking in the corridor, locomotion on and off the unit and dressing. He required extensive assistance of two people for eating. He was totally dependent on two people for toileting and totally dependent of one person for personal hygiene. The resident had one fall within the review period. B.…

  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 · G2023-07-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for two (#25 and #27) of five residents out of 27 sample residents. Resident #25, who was known to be at risk for weight loss due to hemiplegia (paralysis of one side of the body), dementia and dysphagia (difficulty with swallowing), experienced a choking episode on 3/27/23. The facility downgraded the resident to a pureed diet (a diet of foods that do not need to be chewed) and the resident was evaluated by a speech therapist and placed on the speech therapy caseload due to swallowing difficulties for one month. On 3/6/23, three weeks prior to the choking episode, Resident #25 weighed 175.8 pounds (lbs). On 4/5/23, nine days after the choking episode, the resident weighed 165.6 lbs, which was a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2019-10-31 · 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 record review and staff interviews, the facility failed to ensure one (#12) of five residents reviewed out of 29 sample residents remained free from resident-to-resident altercations. The facility failed to implement person-centered interventions and evaluate the effectiveness of the interventions for Resident #12 to protect other residents involved in altercations, and provide person centered care to prevent persistent abuse by Resident #12. Based on the facility's failure to protect Resident #12 and the other residents involved with the altercations, the resident was involved in eight resident-to-resident altercations from 11/26/18 to 10/22/19 which contributed to the harm caused to Resident #31 and Resident #5 on two different occasions. Conversely, Resident #12 was harmed in an altercation with with Resident #1. Findings include: I. Facility policy and procedure The Preventing Resident Abuse policy, dated 11/1/17, was provided by the nursing home administrator (NHA) on 10/30/19 at 5:26 p.m. It read,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2019-10-31 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one (#12) of five residents reviewed for dementia care of 29 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #12 to prevent resident-to-resident altercations, provide an activity program that was personalized to avoid group activities since she desired low stimulation, and address repeated behavioral issues created an environment where abuse persisted. Based on the facility's failure to protect Resident #12 and the residents involved with the altercations, it caused harm to Resident #31 and Resident #5 on two different occasions. The altercation that Resident #12 had harm caused to her was with Resident #1 . The resident was involved in eight resident-to-resident altercations from 11/26/18 to 10/22/19. Cross-reference…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-07 · 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 record review and interviews, the facility failed to ensure two (#1 and #2) of eight residents reviewed for abuse out of eight sample residents were free from abuse. Specifically, the facility failed to ensure Resident #1 and Resident #2 were free from abuse by each other. 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 7/7/25 at 11:00 a.m. It read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-25 · 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 record review and interviews, the facility failed to ensure four (#2, #3, #6 and #9) of nine residents reviewed for abuse out of 13 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #2 from physical abuse by Resident #3; -Protect Resident #6 and Resident #3 from physical abuse from each other; and, -Protect Resident #9 from physical abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 3/24/25 at 2:00 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse by: -Developing and implementing policies and protocols to prevent and identify abuse, neglect 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-12-19 · 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 ensure food items were stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to have a system in place to monitor the internal water temperature and concentration (parts per million-ppm) of hypochlorite of the dish machine in the main kitchen to ensure tableware, drinkware and cookware were effectively sanitized. Findings include: I. Professional reference The Colorado Retail Food Establishment Rules and Regulations, revised March 2024, retrieved on 12/26/24, read in pertinent part: A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided. (page 125) A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified in accordance with the EPA- registered label use instructions . A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as…

  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 · E2024-12-19 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff used the correct surface disinfectant products; -Ensure enhanced barrier precautions (EBP) were in place for a resident with a stage IV pressure injury prior to wound care; and, -Ensure washing machine temperatures were checked daily and lint traps were emptied timely. Findings include: I. Housekeeping A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021)…

  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 · D2024-12-19 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.45%, which was two errors out of 31 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right…

  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 · D2024-12-19 · 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 observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one resident (#3) out of 29 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Residents #3. Cross-reference F759 failure to ensure the medication error rate was less than five percent (%). Findings include: I. Professional reference According to the Instructions for use Humalin R KwikPen, retrieved 12/26/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf It revealed in pertinent Priming your pen. Prime before injections. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensure the pen is working correctly. If you do not prime the pen before injections, you may get too much or too little insulin. II. Facility policy and procedure The Administering medications policy and procedure, revised April 2019, was received from the nursing…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-19 · 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 interviews and record review, the facility failed to protect and keep residents safe from physical abuse for one (#37) of three residents reviewed for physical abuse out of 29 sample residents. Specifically, the facility failed to protect Resident #37 from physical abuse by a staff member. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised September 2022, was received from the nursing home administrator (NHA) on 12/23/24 at 11:00 a.m. It revealed in pertinent part, If resident abuse, neglect, exploitation, misappropriation or 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. Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any)…

  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 · F2024-01-25 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Take the appropriate measures to control a mice problem in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate the mice from entering the facility through door gaps and holes. Findings include: I. Professional reference According to the Center for Disease Control (CDC) revised July 2019 Guidelines for Environmental Infection Control in Health-Care Facilities, retrieved from:https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html Mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-25 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 ensure residents resided in a sanitary and comfortable environment for two of two units observed for cleanliness. Specifically the facility failed to: - Ensure resident rooms, dining rooms, hallways, kitchen floors and furniture were free from debris, food and mice droppings (cross reference F 925 pest control); -Ensure resident furniture and hand rails in common areas were in good repair; and, -Ensure the resident's courtyard was free of hundreds of cigarettes extinguished and disposed of on the ground. Findings include: I. Facility policy and procedures The Common Area Cleaning policy, undated, was received from the nursing home administrator (NHA) via email on 1/25/24 at 12:02 p.m. It read in pertinent part, The lobby and hallways. Damp wipe and disinfect the furniture by damp-wiping the top, inside the drawers, the pulls, the sides, the front and back, and the legs. Clean wall splash marks. Clean walls with your cloth dampened in disinfectant…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-07-17 · 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, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and one out of two nourishment rooms. Specifically, the facility failed to: -Ensure one unit nourishment room was clean and sanitary; -Ensure the kitchen ceiling was free from debris and dust; -Ensure appropriate hand washing occurred in the main kitchen; and, -Ensure dishes were dried appropriately. Findings include: I. Ensure the unit nourishment room was clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; -Time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41º (degrees) F…

  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

“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

$16,801 in federal fines across 1 penalty.

• $16,801 — penalty dated 2024-05-01

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

Part of a chain

This home belongs to MADISON CREEK PARTNERS — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $657K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in CO