Cherrelyn Healthcare Center

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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

Quality measures — how residents actually fare

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.

31.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 17.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 190 beds and averages 179.3 residents a day — about 94% occupied, or roughly 11 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 2.99 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.58 hrs/resident/day on weekends vs 3.16 on weekdays — 18% thinner on weekends. RN hours go from 0.72 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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.

37 citations, most serious first. The 17 most serious are shown; the remaining 20 are one tap away and print in full.

• Actual harm · H2022-06-15 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. As a result of inadequate staffing, the facility failed to provide services and treatment to prevent multiple areas of concern including that resulted in actual harm; abuse prevention, accident prevention, identifying residents who had changes in health conditions so they could receive proper treatment, ensure wound care was provided, and daily provided care such as dressing, toileting, and identify residents who had pain. Cross-reference citations related to resident care that were cited at actual harm: -F600 failure to prevent verbal…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-06-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to protect one (#70) of four residents out of 64 sample residents from abuse by Resident #120. On 6/2/22, Resident #120 verbally abused and threatened his roommate, Resident #70, with physical harm, stating he was going to kill someone. Record review and interview revealed the facility failed to protect Resident #70 from further abuse. Specifically, aware of the abuse, the facility failed to immediately separate the residents even though, per staff, Resident #120 was throwing items, calling names, and slamming doors. Further, there was no documentation Resident #120's behaviors and Resident #70's safety were monitored prior to Resident #120's transfer to the hospital later that evening. Resident #70 reported that until Resident #120 was transferred, he feared for his safety, afraid to close his eyes and go to bed. Cross-reference F609 failure to identify and report abuse. Findings include: I. Facility policy and procedure The Abuse, Neglect and…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-06-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for six (#266, #56, #61, #147, #6 and #119) of eleven residents reviewed for ADL care assistance out of 64 sample residents. Resident #266 was newly admitted to the facility after a medical setback, on 6/1/22, for skilled nursing services including occupational and physical therapy services. The resident goal was to restore as much independence and physical function as possible. The resident required extensive assistance from staff with most of her ADLs. The resident expressed not getting out of bed, not having a wheelchair for mobility and not bathing since her admission on [DATE]. The resident felt uncomfortable, itchy and dirty due to not being bathed and felt lonely and isolated with not getting out of bed. Due to the lack of getting out of her room to move…

  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 · G2022-06-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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 interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two (#26 and #256) of six residents out of 64 sample residents. Resident #26, an insulin dependent diabetic, was experiencing problems with low blood glucose (BG) levels on 3/19/22. The resident was prescribed to have a BG check three times a day prior to each insulin administration. Physician's order dictated the resident's insulin injection was to be held when the result was under 80 and/or the resident was refusing meals. When the nurse assessed the resident's 4:30 p.m. BG level by finger stick, the resident's BG had lowered to 79, under the prescribed parameter of 80. The resident's insulin was held in line with the physician's ordered parameters. One and one half hours later the resident became unresponsive with stroke-like facial paralysis; the resident was only responsive to painful stimuli. The nurse on duty called 911 for emergency…

  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 · G2022-06-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for two (#61 and #143) of five residents reviewed for wounds, out of 64 sample residents. Resident #61 was at risk for developing pressure injuries due to being admitted to the facility on [DATE] with a deep tissue injury to her left side of foot/heel, diagnosis of Alzheimer's disease, encephalopathy (brain disease), and chronic kidney disease stage 3. She required extensive assistance with two people for bed mobility, and total dependence for transfers. There was a delay in assessment by an appropriate staff member, registered nurse (RN) or wound care physician when a new open sacral/coccyx pressure ulcer was discovered 1/27/22 for Resident #61. The sacral wound was not assessed by the wound care physician until 3/1/22 which was approximately five weeks later and at that time was a stage 3 pressure injury. The facility failed…

  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 before2022-06-15 · 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 interviews and record review, the facility failed to ensure the residents' environment remained free from accident hazards as possible, affecting one resident (#264) out of 64 sample residents. The facility failed to develop and implement an effective system of oversight and safety interventions to prevent and reduce the risk of Residents #264 having a smoking accident. Failures included a lack of identification that Resident #264 continued to smoke despite telling the intake coordinator he would not. Failure to assess Resident #264's risks for potential injuries and side effects from smoking. Failure to implementing appropriate interventions to promote Resident #264 being a safer independent smoker; and offering supplies for safer smoking. The facility's failure to identify that Resident #264 would continue to smoke, even with the facility being a non-smoking facility, when admission documentation and physician's notes indicated the resident was an active smoker. The facility failed to develop a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-06-15 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure one (#147) of three residents out of 64 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences. Resident #147, who had a diagnosis of respiratory failure, and history of cerebrovascular accident (CVA, or stroke) with right side hemiparesis (paralysis of the right side of the body), right arm weakness, and contracture in the right hand, was admitted to the facility on [DATE]. The resident stated she had pain in her right hand/forearm with edema and right arm weakness. According to the resident's medical record, the facility failed to address right forearm/hand edema and pain for Resident #147 through proper pain and positioning management. The facility was aware of Resident #147s right hand/forearm pain and edema, however, failed to provide person-centered individualized interventions in the care plan and adjust…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-30 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  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 provide medications as ordered for one (#2) of three out of 14 sample residents. Specifically, the facility failed to have physician ordered medications available at the facility to administer to Resident #2.Findings include: I. Professional reference According to Loss of brain function - Liver Disease, National Library of Medicine MedLine Plus, (8/7/23), retrieved on 1/7/26 from https://medlineplus.gov/ency/article/000302.htm. Loss of brain function occurs when the liver is unable to remove toxins from the blood. This is called hepatic encephalopathy (HE). This problem may occur suddenly, or it may develop slowly over time. An important function of the liver is to make toxic substances in the body harmless. These substances may be made by the body (ammonia), or substances that you take in (medicines). When the liver is damaged, these 'poisons' can build up in the bloodstream and affect the function of the nervous system. The result may be HE. HE can…

  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 · Ecited before2025-01-30 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) for Resident #60, who was on enhanced barrier precautions (EBP); and, -Ensure residents were offered the opportunity for hand hygiene prior to meals. Findings include: I. Failed to ensure staff wore the appropriate PPE for Resident #60, who was on EBP A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), retrieved on 1/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced barrier precautions (EBP) are an infection control intervention…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-30 · tag F0679 — failed to provide activities — isolated
  Provide 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 one (#35) of three residents reviewed for activities out of 59 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being. Specifically, the facility failed to ensure Resident #35 was provided with one-to-one activities and invited to her preferred activities. Findings include: I. Facility policy and procedure The Activities Program policy and procedure, revised June 2018, was received from the director of nursing (DON) on 1/31/25 at 12:41 p.m. It revealed in pertinent part Activity programs are designed to meet the interests and support the physical. Mental and psychosocial well-being of each resident. Activities are offered based on the comprehensive resident-centered assessment and the preferences of each resident. Activities are considered any endeavor, other than routine activities of daily living (ADL), in which the 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-30 · tag F0685 — isolated
  Assist a resident in gaining access to vision and hearing services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#1) of two residents reviewed for vision problems out of 59 sample residents. Specifically, the facility failed to provide Resident #1 assistance in getting new glasses. Findings include: I. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, type two diabetes and chronic obstructive pulmonary disease (COPD). The 10/28/24 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 required substantial/maximal assistance with toileting hygiene, showering/bathing, upper and lower body dressing and personal hygiene. The MDS assessment documented the resident had adequate vision with eye glasses. B. Resident interview…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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 with a feeding tube received appropriate treatment and services for one (#578) of two residents reviewed out of 59 sample residents. Specifically, the facility failed to ensure Resident #578 received his tube feeding administrations as ordered by the physician. Findings include: I. Facility policy and procedure The Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 1/31/25 at 12:41 p.m. It read in pertinent part, Adequate nutritional support through enteral nutrition is provided to residents as ordered. The dietitian, with input from the provider and nurse: estimates calories, protein, nutrient and fluid needs; determines whether the resident's current intake is adequate to meet his or her nutritional needs; recommends special food formulations; and, calculates fluids to be provided (beyond free fluids in formula). Enteral nutrition is ordered by the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-30 · tag F0849 — isolated
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to have a coordinated written plan of care that included both the most recent hospice plan of care and a description of the services furnished by the facility for two (#169 and #12) of three residents out of 59 sample residents. Specifically, the facility failed to ensure Resident #169 and Resident #12 had a written plan of care that included both the most recent hospice plan of care and a description of the services furnished by the facility Findings include: I. Facility policy and procedure A request for the hospice services policy was made on 1/30/25 at 4:15 p.m. to the nursing home administrator (NHA) and was not provided with the other policies requested. The Care Plans, Comprehensive Person-Centered policy, revised March 2022, was provided by the NHA on 1/31/25 at 12:41 p.m. It read in pertinent part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-08-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, in two of two dining rooms and with resident room trays. Specifically, the facility failed to: -Ensure cold food holding equipment and ready to eat perishable food were kept at the appropriate holding temperature in two of two walk-in refrigerators; -Ensure proper unit refrigerator temperatures were maintained in one one of three resident snack refrigerators that contained ready to eat perishable food; -Ensure the high temp dish washing machine functioned at the proper temperatures; -Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in the first floor dining room; and, -Ensure residents were offered hand hygiene before eating their meals in two of two dining rooms and in resident rooms with meal trays. Findings include: I. Cold food holding of ready to eat food and unit refrigerators A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19…

  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 · E2023-08-16 · tag F0550 — failed to protect resident dignity and rights — pattern
  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 observations and staff interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to: -Ensure residents were provided independence and dignity while dining by avoiding the use of disposable cutlery and dishware; and, -Ensure ensure meals were delivered to residents in a timely manner. Findings include: I. Disposable cutlery A. Facility policy The Residents Rights policy, revised February 2021, was provided by the nursing home administrator (NHA) on 8/17/23 at approximately 3:30 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness and dignity; privacy and confidentiality. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our resident's rights. B. Resident interviews 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-08-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 (#151) of one reviewed for medications left unsecured in a common area, two residents (#86 and #23) reviewed for medications at bedside and one (#151) of four residents reviewed for falls out of 56 sampled residents. Specifically, the facility failed to: -Ensure medications were not left unattended for Resident #151's access, who had severely impaired cognition related to dementia and a tendency to wander and pick up items along the way; -Ensure Resident #86 and Resident #23 did not have medications at bedside when not assessed; -Ensure Resident #151 was provide sufficient monitoring, non-slip footwear and other fall interventions the resident was assessed to need in order to prevent multiple falls; and, -Ensure that Resident #151 was assessed by a registered…

  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 · E2023-08-16 · 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 biologics used in the facility were properly stored and labeled for two of three medications carts reviewed for storage and labeling. Specifically the facility failed to: -Ensure Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; and, -Ensure medication carts were maintained clean and free of loose pills. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, revised February 2023, received from the nursing home administrator (NHA) on 8/11/23 at 4:34 p.m. It revealed in pertinent part Nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Multi-dose vials that have been opened or accessed needle puncture were dated and discarded within 28 days. Medications were stored in an orderly manner in cabinets, drawers, and carts to prevent the possibility of mixing medications of several residents. -Insulin which is…

  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

“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

No federal fines in the current CMS record.

Part of a chain

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

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

Who owns this facility

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

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

Follow the money — this home’s finances

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

About 78% 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