Life Care Center Of Longmont
2451 Pratt St, Longmont, CO 80501 · For profit - Corporation · 187 certified beds · (303) 776-5000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has abuse, neglect, or exploitation citations (F0600, F0604) — most recent Mar 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $32,860 in federal fines (most recent 2026-03-12)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.7% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.1% | 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 | 3.2% | 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 | 2.4% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.5% | 13.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.0% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.0% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.7% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.5% | 20.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.7% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.4% | 20.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.7% | 12.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.33 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 1.74 | 1.80 | better |
§ 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.
61.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 374 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 87.4% 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 151 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 0.69 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 32% 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 | 61.5%CMS range 56.1–65.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.9%CMS range 6.6–11.7 | 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 | 87.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 82.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 81.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.5% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.0% | 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 | 7.2%CMS range 4.8–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 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 187 beds and averages 120.7 residents a day — about 65% occupied, or roughly 66 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.58 hrs/resident/day on weekends vs 4.19 on weekdays — 15% thinner on weekends. RN hours go from 0.91 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% 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 more than at the previous inspection — worsening. 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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2026-03-12 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#34) of one resident out of 54 sample residents.Resident #34, was admitted on [DATE] with diagnoses that included Alzheimer's disease and dementia with behavioral disturbance. Resident #34 had a history of behavioral symptoms associated with dementia.On 2/9/26 at 4:30 a.m. certified nurse aide (CNA) #13 entered Resident #34's room to assist CNA #2 who was providing incontinence care. Resident #34 was yelling and striking out during care. CNA #2 said CNA #13 placed one hand over Resident #34's mouth and the other hand over the resident's arms while CNA #2 was providing care. CNA #13 said the facility did not pay her enough to get punched. Interviews completed with the resident's representative revealed Resident #34 would have been fearful if she was able to recall the incident. Specifically, the facility failed to ensure Resident #34 was not physically restrained by CNA…
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 · G2024-01-23 · 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 two (#47 and #73) of five residents out of 36 sample residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable and to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure timely interventions were put in place to prevent the development of a pressure ulcer to Resident #47's left ischium (curved bone at the base of the pelvis). Resident #47 was admitted to the facility on [DATE] and was at risk for the development of a pressure ulcer due to her having a left hip fracture with surgical repair. Despite Resident #47's decreased mobility due to the fracture, which made her a higher risk for developing a pressure ulcer, the facility failed to implement appropriate preventative interventions, such as an alternating pressure air…
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 · F2026-03-12 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide sufficient nursing staff to ensure the resident received the care and services they required in a timely manner. Specifically, the facility failed to ensure residents received their showers as scheduled and call lights were answered in a timely manner for residents dependent on staff for their care. Findings include:I. Facility policy and procedureThe Staffing policy and procedure, revised 3/9/21, was provided by the nursing home administrator (NHA) on 3/12/26 at 5:42 p.m. It read in pertinent part, The facility maintains adequate staff on each shift to meet residents' needs. The facility utilizes the Facility Assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met. II. Resident interviewsResident #129 was interviewed on 3/9/26 at 11:00 a.m. He said staffing seemed to be an issue. He said he felt like there were not enough certified nurse aides (CNAs). He said the night shift…
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 · F2026-03-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature. Findings include:I. Facility policy and procedureThe Food Preparation policy, revised 4/29/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 10:53 a.m. It read in pertinent part, Food is prepared by methods that conserve nutritive value, flavor and appearance. The food that is served to the residents is palatable, attractive and served at the appropriate temperature. Food and drink that is palatable, attractive, and at a safe and appetizing temperature. It also revealed under Definitions, Food palatability refers to the taste and or flavor of the food, and Proper safe and appetizing temperature means both appetizing to the resident and minimizing the risk for scalding and burns. Under Procedure, the policy revealed, Food is seasoned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain proper storage of medications for three out of three medication carts and two of three medication storage rooms.Specifically, the facility failed to:-Label insulin pens with the date they were opened;-Label inhalers with the date they were opened;-Discard medications that had expired;-Keep the cart free of personal items; and,-Ensure medications were labeled with residents' names. Findings include:I. Professional resourceAccording to the manufacturer, Viatris, How to Use a Wixela Inhub (inhaler used to treat asthma and lung disease), 2021, retrieved on [DATE] from https://www.wixelahcp.com/-/media/Project/Common/WixelahcpCom/PDF/[NAME]-2020-0047_V4_US_How-to-Use_PDF.pdf, Take Wixela Inhub out of the foil pouch just before you use it for the first time. Write the pouch opened and use by dates on the label. The use by date is one month from the date you opened the pouch for your first dose.According to the manufacturer Biocon Biologics, 2023,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 three (#31, #71 and #96) of five residents reviewed for abuse out of 54 sample residents. Specifically, the facility failed to:-Protect Resident #31 from physical abuse by Resident #39; and, -Protect Resident #71 and Resident #96 from sexual abuse by Resident #149. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, reviewed 5/6/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 12:18 p.m. It read in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for one (#31) of five residents reviewed for abuse out of 54 sample residents. Specifically, the facility failed to ensure an incident of alleged physical abuse for Resident #31 was reported to the State Survey Agency. Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, reviewed 5/6/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 11:11 a.m. It read in pertinent part, Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received necessary services to maintain proper personal hygiene for two (#11 and #46) of six residents reviewed for ADLs out of 54 sample residents.Specifically, the facility failed to ensure Resident #46 and Resident #11 received assistance with showers. Findings include: I. Facility policy and procedure The ADLs policy and procedure, issued 12/11/18 and reviewed 8/23/23, was received from the nursing home administrator (NHA) on 3/12/26 at 5:55 p.m. It read in pertinent part, The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. For all other ADLs, this facility will utilize…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · 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 residents received treatment and care in accordance with professional standards of practice for one (#46) of four residents reviewed for quality of care out of 54 sample residents.Specifically, the facility failed to ensure physician's orders were obtained and entered for Resident #46's dressing changes following an orthopedic appointment.Findings include:I. Facility policy and procedureThe Physician Orders policy, revised 2/11/26, was received from the nursing home administrator (NHA) on 3/12/26 at 11:11 a.m. It read in pertinent part, The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. All physician/practitioner orders, including verbal/telephone orders, are recorded in the medical record for each resident.II. Resident #46A. Resident statusResident #46, age [AGE], was admitted to the facility on [DATE]. According to the March 2026…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#33) of five residents reviewed for accidents out of 54 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to:-Ensure Resident #33's care plan was accurate and up to date with the resident's correct transfer status; and, -Ensure therapy timely assessed the resident after she sustained bruising related to a transfer. Findings include:I. Professional referenceAccording to the ARJO product guide, retrieved on 3/23/26 from https://www.arjo.com/en-us/products/patient-handling/floor-lifters/#product-list-tab-1, Sara Steady enables a single caregiver to assist patients or residents perform sit to stand transfers throughout the day. The pivoting seat can be moved out to enable the patient to stand, and provides an angled seated support during the transfer. According to the [NAME] Sit-to-Stand Lift product guide, retrieved on 3/23/26 from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#147) of two residents out of 54 sample residents. Specifically, the facility failed to ensure Resident #147's pain medication was administered as ordered and needed per the resident's condition. Findings include:I. Facility policy and procedureThe Pain Management policy was provided by the nursing home administrator (NHA) on 3/12/26 at 1:49 p.m. It read in pertinent part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.II. Resident #147A. Resident statusResident #147, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · tag F0730 — isolatedObserve 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 three (#2, #15, and #16) of five certified nurse aides (CNA).Specifically, the facility had not completed annual performance reviews for CNA #2, #15, and #16 in order to determine potential training needs. Findings include:I. Facility policy and procedureThe Performance Evaluation policy and procedure, reviewed 12/4/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 6:02 p.m. It read in pertinent part, Ongoing performance feedback is strongly encouraged between associates and their supervisors throughout their employment. New associates should receive a formal 90-day evaluation, as should associates newly transferred or promoted to a new role. Annual performance reviews are given to all associates. II. Record reviewAnnual performance reviews were requested on 3/12/26 at approximately 11:33 a.m. Review of the employee files revealed CNA #2'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.
Show the remaining 17 citations
- Potential for harm · D2026-03-12 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 10.34%, which was three errors out of 29 opportunities for error. Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment . Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration . To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights : 1. The right medication2. The right dose3. The right patient4. The right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#34) of 10 residents reviewed for medication administration was kept free from significant medication errors out of 54 sample residents.Specifically, the facility failed to ensure the correct medication was administered to Resident #34 based on the physician's orders. Findings include:I. Professional referenceAccording to the manufacturer, Amneal Pharmaceuticals NY LLC, 2025, Propranolol Hydrochloride (HCL) tablet Drug Label Information, retrieved 3/17/26 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=14d0c95d-418f-40a8-bad3-e20c82424960&audience=consumer, Adverse reactions - The following adverse events were observed and have been reported in patients using propranolol: Bradycardia (low heart rate); congestive heart failure (when the heart is unable to pump blood efficiently); hypotension (low blood pressure); paresthesia of hands (numbness and tingling); arterial insufficiency ( a lack of, or slow blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#62) of two residents reviewed for hospice services out of 54 sample residents.Specifically, the facility failed to implement a hospice care plan for Resident #62 when she was admitted to hospice. Findings include: I. Facility policy and procedureThe Hospice Coordination of Care policy and procedure, revised 9/3/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 11:11 a.m. it read in pertinent part, The facility provides hospice care under a written agreement and must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A delineation of the hospice's responsibilities,…
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 · D2025-09-02 · 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 interviews, the facility failed to notify the resident's representative when there was a significant change in the resident's condition for one (#3) of four residents out of four sample residents. Specifically, the facility failed to notify the designated representative for Resident #3 when he had a fall in the facility.Findings include:I. Facility policy and procedure The Change in Resident's Condition or Status policy and procedure, revised [DATE], was provided by the director of nursing (DON) on [DATE] at 4:47 p.m. It read in pertinent part, A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is an accident or a significant change in the resident's physical, mental or psychosocial status.II. Resident #3A. Resident status Resident #3, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to promote and maintain resident dignity for one (#1) of three residents reviewed out of three sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to ensure dignity was maintained for Resident #1 by emptying urine from her external catheter canister in a timely manner. Findings include: I. Facility policy and procedure The Dignity policy and procedure, dated 9/25/23, was provided by the nursing home administrator (NHA) on 9/9/24 at 4:44 p.m. It read in pertinent part, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as honor and value their input. II. Resident #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-09 · tag F0565 — failed to support the resident council — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to act promptly upon the grievances concerning the issues of resident care and life in the facility that were important to the resident, for one (#1) of three residents out of three sample residents. Specifically, the facility failed to respond timely to Resident #1's grievances regarding long call light wait times and maintain a systematic approach to ongoing resident grievances. Findings include: I. Facility policy and procedure The Grievance policy and procedure, dated 9/25/23, was provided by the nursing home administrator (NHA) on 9/9/24 at 4:44 p.m. It read in pertinent part, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, 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 · Dcited before2024-09-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (#1) of three residents reviewed out of three sample residents. Specifically, the facility failed to: -Arrange medical appointments with a dermatologist and urologist as requested by Resident #1 and ordered by the physician; and, -Arrange for a medical appointment with an infectious disease specialist for Resident #1 in a timely manner. Findings include: I. Facility policy and procedure The Transportation Coordination and Services policy and procedure, dated 6/12/24, was provided by the nursing home administrator (NHA) on 9/9/24 at 4:44 p.m. It read in pertinent part, The facility will assist residents in making necessary appointments for services not provided in the facility and arranging for transportation to and from such appointments. The facility will assist the resident and or 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 · F2024-01-23 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working 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 interviews, the facility failed to maintain the emergency response cart and equipment in safe operating condition for three of three emergency response (crash) carts. Specifically, the facility failed to: -Ensure expired items were removed from the crash cart; and, -Ensure the emergency oxygen canister on the emergency response cart was maintained and ready for use. Findings include: I. Professional references According to [NAME], [NAME], (2022). Crash cart preparedness and failure to rescue a case study review. Retrieved on 1/24/24, from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review and read in pertinent part, A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency. A crash cart is typically located in the setting of an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-23 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and observations the facility failed to develop a comprehensive care plan for four (#38, #55, #66 and #88) of four residents out of 36 sample residents for services to attain or maintain the residence highest practical physical, mental and psychosocial well-being that included measurable objectives and timeframes. Specifically, the facility failed to ensure the comprehensive care plan for Resident #38, Resident #55, Resident #66 and Resident #88 included a focus care plan for oxygen treatment and care. Findings include: I. Facility policy and procedure: The Area of Focus: Care Planning-Baseline, Comprehensive, and Routine Updates policy, not dated, was provided by the nursing home administrator (NHA) on 1/24/24 at 4:57 p.m. It revealed in pertinent part, The Comprehensive Care Plan must be developed after the MDS assessment if completed to address the resident's goals and preferences, contain measurable objectives and timeframe, interventions to assist the resident meets their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for one of three floors at the facility. Specifically, the facility failed to: -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure staff performed hand hygiene in between tasks and at resident's rooms with orders for enhanced precautions; and, -Ensure a vitals machine was disinfected appropriately after use on residents during medication administration. Findings include: I. Failure to ensure residents were provided with an opportunity to participate in hand hygiene before meals and staff performed hand hygiene in between tasks A. Professional reference According to the Center for Disease Control (CDC), Hand Hygiene in Healthcare Settings retrieved on 1/24/24 from: https://www.cdc.gov/handhygiene/providers/guideline.html…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents were provided an environment as free of accident hazards as possible and for one (#58) of five residents reviewed for accidents and hazards out of 36 sample residents. Specifically, the facility failed to investigate skin discoloration and a skin tear of unknown origin and identify hazards and risks for Resident #58. Findings include: I. Facility policy The Incident and Reportable Event Management policy, revised 8/15/23, was received by the nursing home administrator (NHA) on 1/23/24 at 4:00 p.m. It read in pertinent parts: The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents.This includes: a. Identifying hazard(s) and risk(s); b. Evaluating and analyzing hazard(s) and risk(s); c. Implementing interventions to reduce hazard(s) 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 · Dcited before2024-01-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure medications were stored in accordance with accepted professional standards for one of three medication refrigerators Specifically, the facility failed to: -Ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator; and, -Ensure the medication cart was locked when left unattended. Findings include: I. Facility policy and procedure The Storage and Expiration Dating of Medications and Biologicals policy and procedure, revised August 2023, was provided by the nursing home administrator on 1/24/24 at 8:40 a.m. It read in pertinent part, Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. II. Observations On 1/22/24 at 9:33 a.m. the medication refrigerator on the second floor in the medication room was observed with registered nurse (RN) #1. There was one controlled medication locked box in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-09-28 · tag F0553 — failed to let residents help plan their care — widespreadAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to provide 1 (Resident #40) of 1 resident the right to participate in the development and implementation of the resident's care plan. Findings included: A review of undated facility policy titled Area of Focus: Care Planning-Baseline, Comprehensive, and Routine Updates revealed, Comprehensive Care Plan. Developed after the MDS [Minimum Data Set] Assessment is completed to address the resident's goals and preferences, contain measurable objectives and timeframe, interventions to assist the resident' [sic] meets their goals, additional follow-up and clarification, items needing additional assessment, testing, and review with the practitioner, items that may require additional monitoring but do not require other interventions, and the residents' preference and potential for future discharge and discharge plan. A review of Resident #40's quarterly Minimum Data Set (MDS) assessment, dated 08/01/2022, revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating…
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 · D2022-09-28 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #40) of 1 resident retained the right to have personal belongings and to have those belongings treated with respect. Findings included: A review of the facility policy, Inventory of Personal Belongings, revised 07/28/2022, revealed, The resident has the right to be treated with respect and dignity, including: The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. All residents' possessions, regardless of their apparent value to others, must be treated with respect. A review of Resident #40's quarterly Minimum Data Set (MDS) Assessment, dated 08/01/2022, revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating intact cognition. During an observation and an interview on 09/26/2022 at 2:55 PM, Resident #40 stated facility staff threw away a gift from a friend, a bean bag animal, and a Christmas…
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 before2022-09-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility document and policy review, it was determined the facility failed to report an injury of unknown origin for one (Resident #2) of one resident within the required timeframe following identification of the injury. Findings included: A review of the facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect, last revised 08/10/2021, revealed that, in response to allegations of abuse, neglect, exploitation, or mistreatment, staff must Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator 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 · Dcited before2022-09-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure the oxygen tubing and nasal cannula were stored in a sanitary manner when not in use for one (Resident #9) of four sampled residents. Findings included: A review of the facility policy, Oxygen Administration/Safety/Storage/Maintenance, dated 08/02/2021, revealed, Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. A review of Resident #9's Face Sheet revealed the facility admitted the resident with diagnoses which included Alzheimer's disease, dementia, acute respiratory failure, and dependence on supplemental oxygen. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of four, indicating the resident had severely impaired cognition. Per the MDS, Resident #9 required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-03-12 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the past three years. Specifically, the facility failed to ensure three years of survey and investigation findings were available for the public, and where individuals wishing to examine survey results did not have to ask to see them. Findings include: I. ObservationsOn 3/11/26 at 3:15 p.m. the facility's survey results binder was found in the front lobby of the facility. The binder was found to have the findings from the surveys on 9/28/22, 11/12/20, and 9/26/19 . The survey results binder failed to include the facility's most recent recertification survey from 1/23/24 and the last three years of complaint findings. II. Staff interviewsThe nursing home administrator (NHA) was interviewed on 3/11/26 at 3:37 p.m. She said the most recent survey and the last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$32,860 in federal fines across 1 penalty.
- $32,860 — penalty dated 2026-03-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DEVELOPERS INVESTMENT COMPANY INC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 12/31/1991 |
| JOHNSON, KIMBERLY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 11/02/2023 |
| SCHMIDT, DEREK | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 08/01/2023 |
| SIEGEL, JERUSHA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2025 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 04/21/1994 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| LAY, LISA | Individual | CORPORATE OFFICER | since 02/09/2018 |
| SWANKER, RICHARD | Individual | CORPORATE OFFICER | since 04/01/2011 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| LIFE CARE AFFILIATES II | Organization | OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2025 |
| LONGMONT MEDICAL INVESTORS, LTD | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/06/1990 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| HUGHES, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2025 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| PRESTON, FORREST | Individual | LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2000 |
CMS files one row per role, so the 28 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 065282. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.