Sierra Post Acute

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 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 102 beds and averages 82.7 residents a day — about 81% occupied, or roughly 19 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.35 hrs/resident/day on weekends vs 3.98 on weekdays — 16% thinner on weekends. RN hours go from 0.43 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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.

39 citations, most serious first. The 16 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting one (#1) out of three residents reviewed for accident hazards of three sample residents. The facility failed to provide adequate supervision during a smoking break to a resident, who required the use of oxygen. On 8/21/24 Resident #1 exited the behavioral health secured unit door and entered the smoking patio with his oxygen tank and nasal cannula on his face. Certified nurse aide (CNA) CNA #1 and CNA #2 were present to supervise the resident smoking session. CNA #1 was handing out the cigarettes to the residents and CNA #2 was lighting the cigarette for the residents. Resident #1 reached over other residents for his cigarette and CNA #1 handed him a cigarette. Resident #1 proceed to the line to get his cigarette lit. CNA #2 lit his cigarette but did not observe that the resident's oxygen was in place. Resident #1 proceeded to a chair in the…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations record review and interviews the facility failed to ensure that the resident environments remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for for one resident (#10) of three residents reviewed for falls out of sample 34 residents. Resident #10 was admitted on [DATE] for long term care with diagnoses of emphysema (shortness of breath), dementia (impaired memory and thinking), paranoid personality disorder (mental health condition), epilepsy (neurological disorder) and repeated falls. Resident #10 was identified as a high fall risk. Resident #10 sustained eight falls in three months (October 2025 to January 2026).On 10/25/25, Resident #10 sustained a fall where he hit his head. He was sent to the hospital and was diagnosed with a closed head injury. Observations during the survey revealed the facility failed to consistently implement person-centered fall interventions.Specifically, the facility failed to ensure fall…

  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 before2025-10-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#3 and #1) of five residents were kept free from physical abuse out of five sample residents.Resident #3, was admitted on [DATE] with diagnoses of malignant neoplasm of left lung, heart failure, closed nondisplaced intertrochanteric fracture of left femur, unspecified dementia, pulmonary emphysema and post-traumatic stress disorder (PTSD). Resident #4, was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia with psychotic disturbance, cognitive communication deficit, hypertensive chronic kidney disease, and obstructive pulmonary disease.On [DATE] Resident #3 wandered into Resident #4's room. Resident #4 reacted and pushed Resident #3, which caused Resident #3 to fall. Resident #3 sustained a left femur fracture. Specifically, the facility failed to:-Protect Resident #3 from physical abuse by Resident #4; and, -Protect Resident #1 from physical abuse by Resident #2. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#15) of one resident reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 41 sample residents. Resident #15 was admitted to the facility on [DATE]. His admission weight on 9/30/19 was188.4 pounds (lbs). The resident maintained a weight between 180 lbs to 200 lbs between January 2022 and June 2023. The resident was hospitalized in July 2023. When he returned to the facility, the facility failed to weigh the resident until August 2023. The facility did not attempt to weigh the resident after he refused one weight. The registered dietitian (RD) recommended weekly weights in July 2023 and no weights were obtained. Per staff interviews, the resident was not eating, refusing meals and often skipped breakfast and no preventative measures were implemented to address his eating patterns to ensure his intake was adequate. Due to the facility's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-09-15 · 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 record review, observations and interviews, the facility failed to ensure three (#60, #41 and #27) of four residents received adequate supervision to prevent accidents out of 31 sample residents reviewed. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's current medical status, fall risk status and put effective interventions into place to reduce falls and prevent injury for Resident #60. Resident #60, who was admitted to the facility on [DATE], was an identified to be at high risk for falls upon admission due to a recent fall at another facility, which resulted in a subdural hematoma (blood collection on the brain). The facility failed to implement effective person-centered interventions, which considered the resident's compromised medical status to prevent further falls and major injuries. Since the resident's admission to the facility, he experienced seven falls on 7/9/22 with two falls, 7/10/22 with two falls, 7/15/22, 7/16/22 and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-09-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents reviewed received the care and services necessary to meet their nutrition needs and maintain their highest physical well-being level out of 31 sample residents. Specifically, the facility failed to consistently monitor weights, identify significant weight loss, and timely address Resident #6's nutritional needs. Resident #6 experienced a significant, unplanned weight loss of 13% in six months. The facility failed to implement appropriate interventions timely to address Resident #6's significant weight loss. Findings include: I. Facility policy and procedure The Weight Management policy and procedure, revised on 1/17/2020, was provided by the nursing home administrator (NHA) on 9/15/22 at 5:30 p.m. It revealed in pertinent part, Residents are monitored per physician order for significant weight changes regularly. The results are reviewed and analyzed by the facility for intervention as 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-01-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators/freezers.Specifically the facility failed to:-Ensure food was labeled and dated appropriately in the main kitchen and in the nourishment room refrigerators; and,-Ensure food was disposed of timely. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 2/4/26. It read in pertinent part, The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. (Chapter 3-25) 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…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-01-29 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two out of three units.Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers performed hand hygiene while cleaning resident rooms;-Ensure housekeepers cleaned high touch areas; -Ensure dwell times were followed during resident room cleaning; and,-Ensure hand hygiene was conducted appropriately during wound care. I. Housekeeping failures 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) 113:104-114, was retrieved on 2/2/26 from…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-01-29 · tag F0576 — pattern
  Ensure residents have reasonable access to and privacy in their use of communication methods.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interviews, the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls could be made without being overheard on two of three units.Specifically, the facility failed to have a private area for residents to make and receive telephone calls and inform the resident of these areas on the Prasada and Legacy units. Findings include:I. Facility policy and procedureThe Resident Right to Privacy in Communication policy, undated, was provided by the nursing home administrator (NHA) on 1/30/26 at 12:21 p.m. It read in pertinent part, It is the policy of this facility to support and facilitate a resident's right to privacy in communications with individuals and entities within and external to the facility. Reasonable access means that telephones, computers and other communication devices are easily accessible to residents and are adapted to accommodate resident's needs and abilities, such as hearing or vision loss. Policy Explanation and Compliance Guidelines: Have reasonable access 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-29 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure 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

  Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts. Specifically, the facility failed to ensure there were no loose pills in the medication cart. Findings include:I. Facility policy and procedureThe Storage of Medication policy, 2001, and revised on 11/2020, was received from the nursing home administrator on 1/30/26 at 12:21 p.m It revealed in pertinent part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.II. ObservationsOn 1/27/26 at 1:15 p.m., medication cart B was observed with licensed practical nurse (LPN) #1. There were three loose pills in the drawers. LPN #1 said one of the pills was Advil. On 1/27/26 at 1:30 p.m., medication…

  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 · D2026-01-29 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life and recognized the resident for one of three units for dignity.Specifically, the facility failed to treat the resident with dignity during meals. Findings include:I. Facility policy and procedureThe Dignity policy, dated February 2021, was received from the nursing home administrator (NHA) on 1/30/26 at 12:21 p.m. It revealed in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. For example, residents are: provided with a dignified dining experience.The Assistance With Meals/Mealtime policy, undated, was received from the NHA on 1/30/26 at 12:21 p.m. It revealed…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#21 and #32) of five residents reviewed were kept free from abuse out of 34 sample residentsSpecifically, the facility failed to protect Resident #21 from physical abuse by Resident #32. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, was provided by the nursing home administrator (NHA) on 1/26/26 at 2:10 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.II. Incident of physical abuse by Resident #32 towards Resident #21 on 1/5/26A. Facility investigation The facility investigation was provided by the NHA on 1/27/26 at…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide 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 that two residents (#1 and #23) of the three residents reviewed for oxygen received proper respiratory care and services in accordance with professional standards of practice, the residents' care plan, and the residents' choice out of 34 sample residents. Specifically, the facility failed to:-Ensure Resident #1 was provided with continuous oxygen supplementation per the physician's orders; and, -Ensure Resident #23's nebulizer was cleaned appropriately. Findings include: I. Facility policy and procedure The Oxygen Administration policy, revision date October 2010, was received from the nursing home administrator (NHA) on 1/28/26 at 4:55 p.m. It revealed in pertinent part, Review the physician's orders or facility protocol for oxygen administration. Assemble the equipment and supplies as needed. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the January 2026 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop 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 influenza immunizations for one (#5) of five residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to provide the influenza 2025/2026 vaccine to Resident #5. Findings include:I. Professional referenceAccording to the Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2025-26 Influenza Season, dated [DATE]. Retrieved on [DATE] from https://www.cdc.gov/mmwr/volumes/74/we/mm7432a2.htm?s_cid=OS_mm7432a2_w. It revealed in pertinent part, For most persons who require only one dose of influenza vaccine for the season, vaccination should ideally be offered during September or October. However, vaccination should continue after October and throughout the influenza season as long as influenza viruses are circulating and an unexpired vaccine is available.II. 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-26 · 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 record review and interviews, the facility failed to ensure one (#3) of three residents received adequate supervision to prevent accidents out of eight sample residents. The facility failed to develop and implement a person-centered care plan upon Resident #3's admission to the facility that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury. Resident #3 fell on [DATE] (10 days after his admission to the facility. Hospital notes documented a vertebral fracture which required surgical intervention. The facility failed to ensure Resident #3 was assessed by a qualified person, a registered nurse (RN), prior to Resident #3 being moved off the floor. Findings include: I. Facility policy and procedure The Fall Prevention Program policy and procedure, implemented March 2020, was provided by the nursing home administrator (NHA) on 2/26/25 at 12:08 p.m. It revealed in pertinent part, Each resident will be assessed for fall risk and will receive care…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-03-20 · 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 mitigate mice populations in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate 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 on 3/25/24 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…

  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

“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

$54,903 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $18,428 — penalty dated 2026-01-29
• $26,117 — penalty dated 2025-10-20
• $10,358 — penalty dated 2024-09-05
• Medicare payment denial — starting 2023-11-22 for 21 days

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

Part of a chain

This home belongs to PACS GROUP — 274 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

2 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 73% 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 $454K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in CO