Walbridge Memorial Convalescent Wing

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.02 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 30 beds and averages 28.2 residents a day — about 94% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.93 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 4.44 hrs/resident/day on weekends vs 4.93 on weekdays — 10% thinner on weekends. RN hours go from 0.51 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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 unchanged from the previous inspection. 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.

24 citations, most serious first. The 14 most serious are shown; the remaining 10 are one tap away and print in full.

• Actual harm · Gcited before2023-12-14 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and 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, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for three (#19, #9 and #10) of four residents reviewed for mental health out of 29 sample residents. The facility failed to offer alternative mental health services when Resident #9 expressed wanting to die but refused counseling services. Resident #9 was admitted to the facility after a hip replacement and heart issues. Less than six months after she was admitted she was diagnosed with cancer. She did not have signs or symptoms of depression until she fell on 7/4/23 and broke her right arm. She lost her independence and said she felt disgusted with herself since she needed staff to help her with all activities of daily living (ADLs). During her interview, she was withdrawn and had been isolating herself in her room. She said she may never be able to use her right arm like she used to ever…

  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 · G2022-08-25 · 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 observation, record review and interviews, the facility failed to ensure one (#23) of two residents reviewed for skin and pressure injuries, out of 15 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Specifically, Resident #23 developed two facility acquired avoidable pressure ulcers on his back, one of which was unstageable. Resident #23 required assistance with staff for activities of daily living (ADLs) such as dressing but staff did not identify skin concerns on the resident's back until the resident had an unstageable pressure injury with 100% necrotic tissue. The resident was identified at risk for pressure ulcers but had limited pressure ulcer preventive measures in place. The resident also had a decline in condition, food intake and mobility. He was not on a routine turning schedule when he required assistance of staff with bed mobility. Resident #23 preferred to sleep on his back. Resident #23 was not offered an 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-08-25 · 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 VII. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the admission computerized physician orders (CPO), diagnoses included age-related physical debility, repeated falls, and chronic atrial fibrillation. According to the 6/12/22 MDS assessment, the resident was cognitively impaired with a score of six out of 15 on the brief interview for mental status exam. The resident required extensive one person physical assistance with bed mobility, toileting, and transfers. It was noted the resident did not have any falls since admission. B. Record review The admission fall assessment completed on the day of admission 3/8/22 identified the resident was at high risk for falls. Fall #1 A fall note on 3/28/22 at 6:46 p.m. showed the resident fell. Neurological checks were within normal limits, no injuries were noted, and safety concerns were noted as the resident does not call for help and he is resistant to care assistance. A nursing note on 3/29/22 at 1:46 p.m. detailed 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
• Actual harm · G2022-08-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for nutrition/hydration, out of 15 sample residents, maintained acceptable parameters of nutritional status to avoid unintended weight loss. The facility failed to identify and implement timely interventions to maintain the resident's weight. The facility failed to timely respond to Resident #1's significant weight loss. Resident #1 lost 15 pounds (lbs) in one week, resulting in 11.6% total weight loss between 7/10/22 and 7/17/22. The facility did not timely consult with the registered dietitian (RD) after the resident lost 15 lbs. The facility did not incorporate new interventions in response to the weight loss. The resident lost an additional 7 lbs between 7/17/22 and 8/21/22, revealing a total weight loss of 22 lbs at 17.1%. The facility and RD did not attempt to identify the causation of the weight loss or follow physician's orders to check the resident's albumin levels to determine…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-11 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to provide a menu that offered a variety of food options. Specifically, the facility failed to ensure residents were not served a repetitive menu that offered a high quantity of chicken and pork. Findings include:I. Facility policy and procedureThe Menu Planning policy, revised September 2023, provided by the dietary manager (DM) on 12/11/25 at 5:35 p.m. According to the policy, a seven day restaurant style menu shall be used to accommodate general therapeutic diets that would include a variety of selections. II. Resident interviewResident #28 was interviewed on 12/8/25 at 4:23 p.m. Resident #28 said there was too much chicken served on the menu. She said she did not complain because she understood that the large amount of chicken was probably due to a need for cost effective protein. III. Resident group interview Four residents (#7, #26, #27 and #28) who were identified as alert and oriented through facility and assessment the were interviewed in a group setting on 12/9/25 at 12:52 p.m. The residents said they were served…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-11 · 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 and interviews, the facility failed to ensure food was served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure dishes were properly sanitized. Findings include:I. Professional reference According to the Food and Drug Administration Food Code (2022), retrieved on 12/17/25, Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160 degrees F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient…

  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 · D2025-12-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the residents' right to a safe, clean, comfortable and homelike environment for four (#13, #26, #27 and # 28) of seven residents out of 19 sample residents.Specifically, the facility failed to provide washcloths and hand towels in Resident #13, Resident #26, Resident #27 and Resident #28's rooms. Findings include:I. Resident #13A. Resident statusResident #13, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included atrial fibrillation, depression, anxiety, osteoporosis, heart failure and dementia without psychotic disturbance and anemia.The 11/18/25 minimum data set (MDS) assessment revealed Resident #13 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. Resident #13 required substantial assistance with bathing, footwear and lower body dressing. Resident #13 required moderate assistance with toileting…

  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 · D2025-12-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 timely investigate an allegation of abuse involving one (#26) of three residents reviewed for abuse out of 19 sample residents.Specifically, the facility failed to timely investigate and report an allegation of misappropriation of property for Resident #26.Findings include:I. Facility policy and procedureThe Abuse Prevention Program policy, revised September 2023, was provided by the nursing home administrator (NHA) on 12/8/25 at 1:20 p.m. It read in pertinent part, To maintain an abuse free environment and establish guidelines to address suspected occurrences involving resident abuse (mistreatment, exploitation, neglect or verbal, physical or sexual abuse, including injuries of unknown source and misappropriation of resident property). Reports of abuse are promptly and thoroughly investigated. An occurrence report will be filled out within 24 hours by the charge nurse.The abuse policy outlined how to complete an investigation regarding…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-11 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 to ensure received treatment and care in accordance with professional standards of practice for one (#19) of six residents out of 19 sample residents.Specifically, the facility failed to: -Ensure residents' medications were not pre-poured; and,-Administer Resident #19's eye drops in accordance with professional standards.Findings include:I. Professional referencesAccording to the American Academy of Allergy, Asthma and Immunology, retrieved on 12/11/25 from https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/eye-drops, When administering multiple eye medications, wait five to 15 minutes before delivering the second medication to the same eye in order to prevent dilution.According to Fundamentals of Nursing 10th edition by [NAME] and [NAME] et. al, 2021 pp. 672, Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses,…

  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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two (#20 and #16) of four residents out of 19 sample residents. Specifically, the facility failed to:-Implement a recommended brace for Resident #20 to prevent a contracture; and,-Complete an occupational therapy assessment for Resident #16 to evaluate if an assistive device was necessary to prevent contracture, despite a documented decline in the resident's ability to feed herself.Findings include:I. Facility policy and procedureThe Rehabilitative Services policy and procedure, revised 11/1/23, was provided by the nursing home administrator (NHA) on 12/11/25 at 6:12 p.m. It read in pertinent part, We will provide restorative services while maintaining the highest possible level of activities of daily living (ADL). Specialized rehabilitative services must be…

  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 before2025-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#4) of two residents reviewed for accident hazards out of 19 sample residents. Specifically, the facility failed to implement effective fall interventions to prevent falls for Resident #4. Findings include:I. Facility policy and procedureThe Fall Management Program policy, revised February 2021, was provided by the nursing home administrator (NHA) on 12/11/25 at 6:12 p.m. It read in pertinent part, The facility operates in a culture of safety. Staff, residents and family members are encouraged to report any problems or potential problems. A falls management team is responsible for information gathering and developing a plan of action to deal with falls, near misses, and other safety concerns. Within seven days of a fall, the director of long term care or assistant director of long term care will do the following: Review TRIPS (tracking record for improving patient safety) and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-11 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being one (#16) of five residents reviewed for unnecessary medications out of 19 sample residents. Specifically, the facility failed to discontinue or reevaluate a physician's order for Resident #16's as needed (PRN) Lorazepam (an antianxiety medication) after 14 days.Findings include:I. Resident #16A. Resident statusResident #16, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, depression, heart failure and malignant neoplasm of the left breast. The 10/8/25 minimum data set (MDS) assessment revealed that the resident had significant cognitive impairment with short term and long term memory deficits. The assessment revealed Resident #16 had no behavioral symptoms of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-11 · tag F0880 — failed to prevent and control infections — isolated
  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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment.Specifically, the facility failed to implement enhanced barrier precautions for Resident #2 and Resident #8.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 12/19/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-12-14 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to ensure: -Expired foods were disposed of in the activity refrigerator the residents used; -Foods were dated and sealed in the activity refrigerator; -Foods were dated and sealed in the cabinets of the activity kitchenette; and, -Kitchen staff practiced good hand hygiene and proper glove use while preparing and serving ready-to-eat foods to the residents. Findings include: I. Activity kitchenette A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/27/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$29,981 in federal fines across 1 penalty.

• $29,981 — penalty dated 2023-12-14

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

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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

What families pay in CO