Bent County Healthcare Center
810 3rd St, Las Animas, CO 81054 · Government - County · 56 certified beds · (719) 456-1340 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,442 in federal fines (most recent 2023-08-24)
- its payroll-based staffing score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 4 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 improved from 3 to 4 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 | 1.3% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 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 | 0.6% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.2% | 8.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.1% | 13.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.7% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.4% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.5% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.0% | 20.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 36.0% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.0% | 20.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.6% | 12.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.00 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.82 | 1.74 | 1.80 | worse |
§ 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.
48.9% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 48.9%CMS range 35.7–61.6 | 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 | 9.6%CMS range 5.9–15.2 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 56 beds and averages 50.0 residents a day — about 89% occupied, or roughly 6 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 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.92 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.81 is at or above 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 3.59 hrs/resident/day on weekends vs 4.18 on weekdays — 14% thinner on weekends. RN hours go from 0.93 to 0.89 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2023-08-24 · 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 observations, record review and interviews, the facility failed to ensure one (#105) of three sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. During the 4/28/23 visit, the surgeon removed the sutures and staples from the surgical site on both sides of the right ankle. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. The order also noted to keep the boot on except for baths. The resident had complaints of pain to the right lower extremity on 5/11/23. The nurse assessed the area and found the ankle surgical sites had opened. The facility had not assessed or monitored…
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 · G2023-08-24 · 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 for one (#1) of two residents reviewed for pressure injuries received care consistent with professional standards of practice. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. The orders also noted to keep the boot on except for baths. The resident had complaints of pain to the right lower extremity on 5/11/23. The nurse assessed the area and found the resident had developed an unstageable pressure injury to the right heel. The facility had not assessed or monitored the ankle for 12 days. Cross-reference F684, quality of care, regarding failure to assess and monitor surgical sites. Findings include: I. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-01 · 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 and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the kitchen, entrance to the dish room and the dish receiving room were identified and corrected in a timely manner. Findings include: I. Facility policies and procedures The Floors policy, revised December 2009, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:51 a.m. The policy revealed all floors should be mopped, cleaned and or vacuumed daily in accordance with the facility's established procedures. The environmental services director (ESD) maintained floor-cleaning procedures. Inquiries concerning floor care should be directed to the director of housekeeping services. The Maintenance Service policy, revised December 2009, was provided by the NHA on 5/1/25 at 11:45 a.m., the policy revealed maintenance services should be provided to all areas of the facility, ground 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 · E2025-05-01 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure four (#29, #32, #35 and #36) out of 14 received activities to meet the needs and interests of the residents out of 20 sample residents. Specifically, the facility failed to: -Provide person-centered activities for Resident #29, Resident #32, Resident #35 and Resident #36; and, -Ensure Resident #32 and Resident #36 were assisted to a group activity when they requested to attend. Findings include: I. Facility policy and procedure The Activities policy, revised June 2018, was provided by the nursing home administrator (NHA) on 5/1/25 at 5:29 p.m. It read in pertinent part, Attendance and participation is recorded for every resident in group and individual activities on a daily basis. Records are reviewed on a regular basis, and at least quarterly, to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review. Attendance records are used when completing…
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 · D2025-05-01 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one (#36) out of one of 20 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure Resident #36 received nectar thick liquids per physician's orders. Findings include: I. Manufacture's recommendations The Simply Thick Easy Mix packet was provided by the director of nursing (DON) on 5/1/25 at 11:05 a.m., the directions read: add to four fluid ounces (oz) (120 milliliters - ml) of liquid. Stir briskly for 30 seconds. II. Facility policy and procedure The Dysphagia Clinical Protocol was provided by the nursing home administrator (NHA) on 5/1/25 at 2:14 p.m. It read in pertinent part, The staff and physician will identify individual with a history of swallowing difficulties or related diagnoses such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food. If a swallowing problem is identified or suspected, 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.
- Potential for harm · Fcited before2024-09-19 · tag F0925 — failed to control pests — widespreadMake 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
Based on observations, record review and interviews the facility failed to maintain an effective pest control program so the facility was free from pests and cockroaches, in one of one kitchen and one of two dining rooms. Specifically, the facility failed to: -Ensure an effective pest control program that eliminated the presence of live and dead cockroaches in the kitchen and dining room, food preparation area, storage area, serving and eating areas; -Ensure dead and decaying roaches were removed from the dining room lower cupboard space; and, -Ensure heavily occupied sticky pest traps, containing a large amount of trapped dead and decaying cockroaches were removed timely and when the traps were full. Findings include: I. Professional references According to the Colorado Department of Public Health and Environment, Colorado Retail Food Establishment Regulations, effective 3/16/24, was retrieved on 9/25/24 from https://cdphe.colorado.gov/dehs Controlling Pests. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other…
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 · F2023-08-24 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake 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
Based on observation and staff interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on a hose in the biohazard room sink, west shower room and the south shower room, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 8/23/23 at 2:24 p.m. revealed backflow prevention devices were not installed on the hose in the biohazard room, west shower and south shower room hand held shower. The hose in the biohazard room was utilized to rinse soiled items. The hose was sitting inside the rinse sink which had standing water on the bottom of the sink. The hand held showers in the west and south shower rooms were long enough for the nozzle end to be submerged beneath the level of the drain threshold. II. Staff Interview The maintenance supervisor (MTCE) was interviewed on 8/24/23 at 9:30 a.m. He said the hose in the biohazard…
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 · E2023-08-24 · 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 provide response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity. Findings include: I. Facility policy and procedure The Grievance policy, undated, was provided by the nursing home administrator (NHA) on 8/23/23. It read it pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance. The resident, or person filing the grievance on behalf of the resident, will be informed (verbally and in writing) of the findings of 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 · E2023-08-24 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 13 of 32 resident rooms in three hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment were conducted on 8/23/23 at 2:24 p.m. revealed: room [ROOM NUMBER]: The wall next to the window had three dime sized holes. The baseboard cove next to room [ROOM NUMBER] was missing a section approximately five inches long by four inches high. room [ROOM NUMBER]: The wall next to the sink had a plastic corner piece which was broken with a sharp edge approximately three inches long. The wall in the bathroom had deep scratches from the wheelchair hitting the wall. room [ROOM NUMBER]: The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. The wall in the bathroom had an area approximately six inches wide by 14…
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 before2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure safe water temperatures. Findings include: I. Water temperature observations 8/21/23: -At 9:02 a.m., the temperature of the tap water was obtained in room [ROOM NUMBER]. The water was found to be 139 degrees Fahrenheit (F); -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; The [NAME] shower room [ROOM NUMBER].4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F. -At 10:09 a.m., certified nurse aide (CNA) #1 observed the temperature of the resident's water in room [ROOM NUMBER]. The temperature was 139.4 degrees F. CNA #1 said the thermometer reading was 139.4 degrees F. CNA #1 was unsure what 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 · E2023-08-24 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for four of five certified nurse aides (CNAs), one of one licensed practical nurses (LPNs) and four of four registered nurses (RNs). Specifically, the facility: -Failed to complete competencies as identified in the facility assessment for CNAs #1, #2, #4, and #5; -Failed to complete competencies as identified in the facility assessment for LPN #1; and -Failed to complete competencies as identified in the facility assessment for RNs #1, #3, #4, and #5. Findings include: I. Facility assessment The facility assessment, reviewed 6/7/23, identified the staff training topics provided by the facility to meet the needs of the residents, which read in pertinent part: Facility training topics are conducted at hire, annually, and as needed. -Be sufficient to ensure the continuing competence of nurse aides, but…
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 · E2023-08-24 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
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 a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for four of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #1, CNA #2, CNA #4 and CNA #5. Findings include: I. Record review CNAs #1, #2, #4, and #5 did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interviews The staff development coordinator (SDC) was interviewed on 8/23/23 at 1:10 p.m. She said she was not aware nurse aide performance reviews were required annually. She said going forward there would be performance reviews completed. The director of nursing (DON) was interviewed on 8/24/23 at 10:23 a m. She said the facility had not completed any annual performance reviews. She said it would help support the aides…
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 14 citations
- Potential for harm · Ecited before2023-08-24 · 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, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Food was stored and labeled properly. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36, Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. B. Observations and staff interview On 8/23/23 at 9:55 a.m., dietary aide (DA) #1 had just completed preparing minced moist mechanical soft meals of chicken tarragon. DA #1 placed the minced moist mechanical soft chicken into a metal pan 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 · Ecited before2023-08-24 · tag F0925 — failed to control pests — patternMake 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
Based on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies. Findings include: I. Professional references A. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) page 186, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. B. According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019, pp. 95-96: -Insects can serve as agents for 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 · D2023-08-24 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#8) of four residents reviewed for PASRR out of 24 sampled residents. Specifically, the facility failed to notify the State Mental Health Agency when recommendations had not been met for Resident #8. Findings include: I. Facility expectations Pre-admission Screen and Resident Review training provided to the social services director (SSD) on 3/29/22 was provided by the nursing home administrator (NHA) on 8/23/23. It read in pertinent part: Specialized services: If a nursing facility cannot arrange or provide specialized services, it must transfer the resident to an appropriate nursing home. Psychiatric case consultation is defined as the addition of a psychiatrist or psychiatric prescriber to a resident'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.
- Potential for harm · D2023-08-24 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 each resident was being screened for a mental disorder prior to admission or that residents identified with a mental disorder were evaluated to receive care and services in the most integrated setting to meet their needs for two (#12 and #24) of five residents reviewed out of 24 sample residents. Specifically the failed failed to: -Obtain a level I screening for Resident #12 who suffered from mental illness (MI) prior to admission so a level II evaluation and determination could be completed by the State Mental Health Agency; -Notify the State Mental Health Agency Resident #24 had exceeded the 30 day provisional preadmission screening and resident review (PASRR) period; and -Submit a new PASRR to the State Mental Health Agency for Resident #24 to determine if a level II evaluation was needed. Findings include: I. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician…
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 before2023-08-24 · 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 resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#27 and #28) of two residents reviewed for supplemental oxygen use out of 24 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Residents #27 and 28. Findings include: I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 8/23/23 at 2:47 p.m. by the nursing home administrator (NHA). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. II. Resident # 27 A. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included schizophrenia, heart failure, left bundle-branch block, schizoaffective disorder, and hypoxia. According to the 7/31/23 minimum data set (MDS) assessment, the resident had moderate cognitive…
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 · D2023-08-24 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 were provided medically related social services to attain and maintain the highest practicable mental and psychosocial wellbeing for three (#24, #12, and #9) of five residents reviewed out of 24 sample residents. Specifically, the facility failed to ensure: -Social services was providing and arranging needed mental and psychosocial counseling services for Residents #24 and #9; -Social services was meeting the needs of residents who were having difficulty with change, loss, and adjustment for Residents #24, #12 and #9; and -Social services was meeting the need for emotional support for residents suffering from suicidal ideations and changes in mental health symptoms for Residents #24 and #12. Findings include: I. Facility description of medically related social services The resident services director (social services director) job description signed by the social services director (SSD) on 10/6/2010 was provided by the nursing home…
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 · D2023-08-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 each resident's drug regimen was free from unnecessary drugs for one (#39) of five residents reviewed for unnecessary medications. Specifically, the facility failed to ensure the ordered antibiotic was effective to treat the resident. Findings include: I. Resident status Resident #39, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and urinary tract infections. The 5/8/23 minimum data set (MDS) assessment revealed the resident was unable to conduct a brief interview for mental status (BIMS) due to severe cognitive decline. During the look back period, she had received an antibiotic seven out of seven days. II. Record review The August 2023 CPO included an order for Keflex 250 mg (cephalexin). Give one capsule by mouth at bedtime for recurrent urinary tract infections (UTIs). The order started…
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 · D2023-08-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 three (#24, #12, and #9) of five residents reviewed were free from unnecessary psychotropic medications out of 24 sample residents. Specifically, the facility failed to monitor targeted behaviors and provide non-pharmacological interventions for psychotropic medications for Residents #24, #12 and #9. Findings include: I. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder, alcohol induced dementia, and depression. The 7/12/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident's depression screen revealed a score of 14 out of 27 indicating moderate depression. No behaviors were indicated. B. Resident interview Resident #24 was interviewed on 8/22/23 at 9:52 a.m. The resident stated he…
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 · D2023-08-24 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure menus met the needs of residents and were followed. Specifically, the facility failed to ensure menu items were not omitted from the lunch menu service for all residents. Findings include: I. Lunch meal menu on 8/23/23 The menu called for 3 ounces of chicken tarragon, one cup of roasted potatoes, one cup of herbed green beans, wheat roll and pudding parfait. Pureed diet: The menu called for 3 ounces of chicken tarragon, one cup of mashed potatoes, one cup of herbed green beans, wheat roll and pudding parfait. II. Lunch meal observation on 8/23/23 The menu had a main entree of chicken tarragon, one cup of roasted potatoes, one cup of herbed green beans, and pudding parfait. B. Observations During observations of the tray line service in the main dining room during the noon meal on 8/23/23 wheat rolls were not observed to be served for the residents who had pureed texture and regular meals. Pureed bread was not observed on the tray line. The bread was omitted from all of the meals. C. Staff Interviews The dietary aide…
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 · D2022-06-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure immediate physician notification for one (#15) of five residents reviewed out of 25 sample residents. Specifically, the facility failed to notify the physician of Resident #15's high blood sugars/glucose levels that were out of physician ordered parameters. Findings include: I. Resident status Resident #15, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to June 2022 computerized physician orders (CPO), diagnoses included type two diabetes mellitus, bacteremia, anxiety and depression. The 3/14/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score 15 out of 15. She required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and personal hygiene, and supervision with eating. Medications included daily insulin injections, antidepressant, anticoagulant, antibiotic and diuretic. II. Record review Review of 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 · D2022-06-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 the minimum data set assessment (MDS) accurately reflected residents' status for three (#20, #26 and #32) of 16 out of 25 sample residents. Specifically, the facility failed to appropriately assess, according to the Resident Assessment Instrument (RAI): -Behavior-Psychosis for Resident #20; -Medications for Resident #26; and, -Restraints-Alarms for Resident #32. Findings include: I. Resident #20 A. Resident status Resident #20, age [AGE], was admitted to the facility on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Parkinson's disease, anxiety disorder, repeated falls, dementia with behavioral disturbance, and hallucinations. The 3/29/22 minimum data set (MDS) assessment revealed intact cognition with a brief interview for mental status (BIMS) score 14 out of 15. Section E (Behavior) documented verbal behavioral symptoms directed toward others occurred one to three days. No hallucinations 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 · D2022-06-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 develop and implement a comprehensive, resident centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (#26) of 16 out of 25 sample residents. Specifically, the facility did not ensure Resident #26's comprehensive care plans were developed and included appropriate preventative interventions and treatments for wounds on her buttocks. Findings include: I. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, diagnoses included cerebral infarction, acute osteomyelitis of left ankle and foot, end stage renal disease, dementia with behavioral disturbance, and type two diabetes mellitus. The 3/19/22 MDS assessment revealed severely impaired cognition with BIMS score six out of 15. She required supervision with bed mobility and eating, limited assistance of two staff with transfers and toilet use, and limited…
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 before2022-06-09 · 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 the resident environment remained as free of accident hazards as possible for one (#20) of three residents reviewed for falls out of 25 sample residents. Specifically, the facility failed to comprehensively review, implement effective interventions and update the resident's care plans after multiple falls for Resident #20. Findings include: A. Resident status Resident #20, age [AGE], was admitted to the facility on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Parkinson's disease, anxiety disorder, repeated falls, dementia with behavioral disturbance, and hallucinations. The 3/29/22 minimum data set (MDS) assessment revealed intact cognition with a brief interview for mental status (BIMS) score 14 out of 15. Section J (Health Conditions-Fall History) indicated the resident had falls prior to admission to the facility. Section G (Functional Status) revealed bed mobility, transfers, walking, dressing,…
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 before2022-06-09 · 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 residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#41) of three residents reviewed for oxygen therapy out of 25 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Residents #41. Findings include: I. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Resident #41 A. Resident status Resident #41, above the age of 90, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), heart failure and cardiac pacemaker. The 5/1/22 minimum data set (MDS) assessment revealed the resident was cognitively…
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
$13,442 in federal fines across 1 penalty.
- $13,442 — penalty dated 2023-08-24
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SUMMERS, JEREMY | Individual | CONTRACTED MANAGING EMPLOYEE | since 03/14/2012 |
| THOMAS, JOHN | Individual | CORPORATE OFFICER | since 06/04/2015 |
| BENT COUNTY | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/1997 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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 74% 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.
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Colorado Medicaid page.
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 065359. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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 →
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