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Rock Creek Rehabilitation And Healthcare Center

2277 East Dr, Monte Vista, CO 81144 · For profit - Limited Liability company · 60 certified beds · (719) 852-5138 Medicare & Medicaid certified

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Flagged for abuseResident-funds citation (F0565)Behavioral-health or dementia-care citations — no harm found (F0740, F0744)2 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$37,103 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — 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
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $37,103 in federal fines (most recent 2025-12-10)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Dr. Oliver12.7 mi
Antoinette Robinson · (434) 373-0249 · Call to confirm hours
Pharmacy
222 Solar Ave · (719) 852-9894 · Call to confirm hours
Grocery
Safeway1.2 mi
1200 2nd Ave · (719) 852-5121 · Call to confirm hours
Park
1568 Grande Ave · Typically dawn to dusk
Place of worship
2160 Sherman Ave · (719) 852-5090

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.4%13.4%15.4%better
Long-stay residents who lose too much weight6.5%4.7%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.8%1.4%2.0%better
Long-stay residents with depressive symptoms60.5%8.8%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury7.9%3.4%3.3%worse
Long-stay residents whose ability to walk worsened13.0%13.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.4%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine93.8%94.7%95.3%typical
Long-stay residents with pressure ulcers4.1%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control14.5%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table35.4%20.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.6%1.4%better
Long-stay hospitalizations per 1,000 resident days1.091.381.67better
Long-stay outpatient ER visits per 1,000 resident days3.711.741.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

§ 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.

10.6%U.S. median 10.7%
Went back to hospital
0.11U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.5–16.410.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 2022–Sep 2024CMS 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

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

8
deficiencies at the latest standard inspection (2026-05-20)
10
at the previous standard inspection (2024-02-08)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2026-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews the facility failed to ensure two (#25 and #35) of eight out of 24 sample residents were kept free from abuse.Specifically, the facility failed to: -Protect Resident #25 from verbal abuse from Resident #3 on 12/15/25 and 12/21/25, which caused psychosocial distress for Resident #25; and,-Protect Resident #35 from verbal abuse from Resident #3 on 12/23/25 and 12/31/25, which caused Resident #35 to become tearful after both incidents. Resident #3, who was admitted to the facility on [DATE] and readmitted on [DATE], was known to have verbally aggressive behaviors toward others and had been involved in verbal altercations with other residents.On 12/15/25 Resident #3 verbally abused Resident #25 in the dining room by yelling foul language, making threatening comments and moving aggressively toward Resident #25. The facility placed both residents on 15-minute checks and educated staff regarding de-escalation techniques. However, six days later, on 12/21/25, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited 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 record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards received adequate supervision out of four sample residents.Resident #1, who was dependent on facility staff for wheelchair mobility, sustained a fall from her wheelchair on [DATE], which resulted in a cervical spine fracture.During the facility's investigation of the fall, it was discovered that staff failed to attach the foot pedals to Resident #1's wheelchair. As a result, Resident #1 was unable to rest her feet on the foot pedals while being transported. On [DATE], while Resident #1 was being transported from the dining room to her room, Resident #1 caught her foot/feet on the rug, fell forward out of the wheelchair, and hit her head on the floor as she fell.Due to the facility's failure to ensure staff used wheelchair safety equipment/foot pedals, Resident #1 sustained a fall on [DATE], which resulted in a cervical (C1) spine fracture. Specifically, the facility failed to ensure…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2024-02-08 · 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, interviews and record review, the facility failed to ensure the environment was free of accidents and hazards for two (#16 and #4) of four residents reviewed for falls out of 17 sample residents. Resident #16, who was at high risk for falls, sustained 17 falls from 9/4/23 to 1/31/24. The facility failed to ensure fall interventions were implemented after each fall and implement effective interventions when they were added. The resident, who required maximum assistance with toileting according to her care plan, often fell trying to go to the bathroom. Due to the facility's failures to implement effective interventions, Resident #16 had a major injury on 1/9/24 when she fell trying to go to the bathroom which required hospital treatment for a head laceration where she had two staples. Observations during the survey from 2/5/24 to 2/8/24 revealed the facility had not consistently implemented fall interventions. In addition, the facility failed to ensure fall interventions were utilized…

    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 before2026-05-20 · 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 observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition;-Maintain the ice machine in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated and discarded within appropriate use-by timeframes.Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. (6-501.12) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (4-601.11) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11) The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment. (6-501.114)B. ObservationsThe initial tour 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-20 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to take appropriate corrective actions, as a result of abuse investigations, for four of nine abuse allegations. Specifically, the facility failed to take appropriate corrective action following the investigations of four verbal abuse incidents by Resident #3 towards Resident #25 on 12/15/25 and 12/21/25, and Resident #35 on 12/23/25 and 12/31/25, to ensure that verbal abuse did not recur.Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised 9/22, was provided by the nursing home administrator (NHA) on 5/21/26 at 11:32 a.m. It read in pertinent part, All allegations are thoroughly investigated. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The individual conducting the investigation reviews the documentation as evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 chemical restraints for one (#7) of five residents out of 24 sample residents. Specifically, the facility failed to ensure Resident #7, who was receiving an antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements that can be caused by taking antipsychotic medications) did not worsen.Findings include: I. Professional reference According to the National Institute of Health (NIH) National Library of Medicine's Impact of A Pharmacist-Driven Tardive Dyskinesia Screening Process (7/16/21), retrieved on 5/26/26 from https://pmc.ncbi.nlm.nih.gov/articles/PMC8287863/#s1, According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), tardive dyskinesia (TD) is defined as involuntary movements generally of the tongue, lower face, jaw, torso, and extremities that are developed from the use of antipsychotics. These movements…

    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 · D2026-05-20 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 and document sufficient discharge preparation for one (#22) of one resident reviewed for a safe and orderly discharge out of 24 sample residents.Specifically, the facility failed to ensure a written bed hold notice was provided to Resident #22 and/or her representative at the time of the resident's transfer to the hospital.Findings include:I. Facility policy and procedureThe Bed-Holds and Returns policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 11:57 a.m. It read in pertinent part, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for one (#10) of two residents out of 24 sample residents.Specifically, the facility failed to maintain, clean, sanitize and properly store Resident #10's nebulizer machine (breathing treatment device) and mask.Findings include:I. Resident #10A. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (chronic lung disease), dependence on supplemental oxygen, and hypertension (high blood pressure).The 3/3/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment documented the resident used continuous oxygen therapy.B. Resident interview and observationsResident #10 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 (#37) of one resident reviewed for pain out of 24 sample residents. Specifically, the facility failed to:-Ensure a thorough pain assessment was completed that identified Resident #37's history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident's quality of life; -Identify Resident #37's goals for pain management and the resident's acceptable level of pain; -Ensure Resident #37's location of pain was consistently identified when administering pain medication to the resident; and, -Ensure Resident #37's pain medication was administered as ordered and needed, based on the resident's observed status.Findings include: I. Facility policy and procedure The Pain Assessment and Management policy and procedure, revised…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well being for one (#3) of seven residents out of 24 sample residents. Specifically, the facility failed to identify Resident #3's history of depression to monitor and provide ongoing assessment to determine whether the care approaches met the emotional and psychosocial needs of the resident.Findings include: I. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and depressive disorder.The 3/10/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. He required partial assistance with bathing, dressing, and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for acute changes in condition out of four sample residents.Specifically, the facility failed to timely notify the physician and intervene to treat high blood pressure for Resident #1.Findings include:I. Professional reference The article Hypertensive crisis: What are the symptoms? (2024) was retrieved on [DATE] from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/hypertensive-crisis/faq-20058491?cjdata=MXxOfDB8WXww&cjevent=765460d1cfad11f082c907180a1cb829&cm_mmc=CJ-_-100357191-_-5250933-_-Evergreen+Link+for+Mayo+Clinic+Diet&utm_source=cj&utm_content=100357191&utm_capaign=3-months read in pertinent part; A hypertensive crisis is a sudden, severe increase in blood pressure. The blood pressure reading is 180/120 millimeters of mercury (mmHg) or greater. A hypertensive crisis is a medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for maintaining resident health records out of four sample residents.Specifically, the facility failed to ensure physicians' progress notes for Resident #1 were available in the electronic medical record (EMR).Findings include:I. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 6/8/25. According to the June 2025 computerized physician orders (CPO), diagnoses included high blood pressure, diabetes mellitus and Alzheimer's disease.The 5/8/25 minimum data set (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily…

    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 · E2024-02-08 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning staff, laundry and housekeeping. Findings include: I. Facility policy and procedure The Grievance policy, which was undated, was provided by the nursing home administrator (NHA) on 2/7/24 at 11:05 a.m. It read it pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance. The resident, or person filing the grievance on behalf of the resident, will be informed (verbally and in writing)…

    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
Show the remaining 18 citations
  • Potential for harm · E2024-02-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for six of 22 resident rooms in two hallways. Specifically, the facility failed to ensure blinds were intact in six resident rooms. Findings include: I. Environmental tour and interview The environmental tour was completed with the nursing home administrator (NHA) and the maintenance director (MTCE) on 2/8/24 at 9:03 a.m. The following items were found: Resident rooms #2, #4, #31, #33, #35 and #37 had broken blinds covering the windows. The NHA said prior to the ongoing change of ownership the facility was only ordering a few items at a time. She said the blinds may have been ordered previously and the facility was waiting for the delivery. She said it was important for the residents' privacy to have intact blinds. II. Record review The December 2023 resident council meeting minutes documented the facility had informed the residents they were going to get estimates to replace the blinds. III. Facility follow up The NHA provided an order receipt for the blinds…

    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 · E2024-02-08 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility failed to have a RN on duty for eight consecutive hours on a consistent basis from 11/1/23 to 2/5/24. Findings include: I. Record review Review of the nursing schedule from 11/1/23 to 2/5/24 revealed the following: -In November 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month; -In December 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month; -In January 2024, the facility did not have a RN on duty for eight consecutive hours on four days during the month; and, -In February 2024, from 2/1/24 to 2/5/24, the facility did not have a RN on duty for eight consecutive hours for one day. II. Staff interview The director of nursing (DON) was interviewed on 2/7/24 at 10:26 a.m. She said she was not aware of the federal requirement regarding the need for a RN for eight consecutive hours seven days a week. She…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-08 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for four (#13, #3, #16 and #20) of five residents reviewed for vaccinations of 17 sample residents. Specifically, the facility failed to ensure Residents #13, #3, #16 and #20 were offered and/or received pneumococcal immunization. Findings include: Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), Pneumococcal Vaccine Recommendations website, revised 9/21/23, retrieved on 2/13/24 from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html read in pertinent part, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for one (#13) out of 17 sample residents. Specifically, the facility failed to ensure the discharge planning process focused on Resident #13's discharge goals. Findings include: I. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and developmental disorder of scholastic skills (learning disability). The 1/11/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She used a wheelchair for mobility and required substantial staff assistance with transfers, toileting, showering, and dressing. The section about discharge planning and goals revealed the resident had not been interviewed but had been interviewable. The legal…

    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 · D2024-02-08 · 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 received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable for one (#23) of two residents reviewed for mobility out of 17 sample residents. Specifically, the facility failed to ensure a carrot contracture prevention device was placed according to physician orders for Resident #23. Findings include: I. Resident #23 A. Resident status Resident #23, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included muscle weakness and Parkinson's disease. The 11/15/23 minimum data set (MDS) assessment revealed the resident's mental status was severely impaired. The assessment did not identify functional limitations in the upper extremities. B. Observations Resident #23 was in her room on 2/5/23 at 9:53 a.m. with no carrot…

    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 · D2024-02-08 · tag F0730 — isolated
    Observe 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 of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #3 (hired on 10/20/15), CNA #4 (hired on 6/16/93) and CNA #5 (hired on 10/1/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 2/7/24 at 10:30 a.m. She said she could not locate the performance reviews for CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication rooms. Specifically, the facility failed to date a multi use vial of tuberculin when opened. Findings include: I. Professional reference According to the Tubersol package insert, retrieved 2/12/24 from: https://www.fda.gov/media/74866/download, A vial of Tubersol which has been entered and in use for 30 days should be discarded. II. Observation and interview The medication room was reviewed on 2/6/24 at 1:15 p.m. An opened multi use vial of Tubersol was in the refrigerator. -There was no date on the vial to indicate when the medication was opened. Licensed practical nurse (LPN) #1 said she did not know when the vial was opened. She said it should have been dated when opened for the safety of the residents. III. Additional interview The director of nursing (DON) was interviewed on 2/6/24 at 3:30 p.m. She said Tubersol was good for 30 days after opening. She said the vial should…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-10-10 · tag F0726 — failed to have competent, trained nursing staff — widespread
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interviews, the facility failed to ensure certified nurse aides (CNAs) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to complete staff competencies for all CNAs. Findings include: I. Competency records The facility did not have competency records for CNA skills. II. Interviews CNA #2 was interviewed on 10/8/19 at 1:45 p.m. He said he was trained on the correct way to turn on oxygen for a resident on either a concentrator or a portable tank about five years ago. (Cross-reference F695, respiratory care.) The director of nursing (DON) was interviewed on 10/9/19 at 2:30 p.m. She said the facility could not locate the competencies of the CNAs providing care in the facility. She said the facility was going to schedule a skills fair in December.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-10-10 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    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 establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program for one (#1) of five residents reviewed of 18 sample residents. Specifically, the facility: -Failed to track antibiotic usage in the facility, and -Failed to assess for the appropriate use of an antibiotic for Resident #1. Findings include: I. Professional standard The Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on 10/17/19, included the following recommendations: Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities…

    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 · F2019-10-10 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies. Findings include: I. Professional references A. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) page 186, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. B. According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated 2/15/17, pp. 94-95: -Insects can serve as agents for the mechanical…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-10-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews, the facility failed to store and prepare food under sanitary conditions. Specifically, the facility failed to ensure: -Cutting boards were free from deep scratches and stains; and -Food was stored properly, off the floor. Findings include: I. Cutting boards A. Professional Standard According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 10/7/19 at 10:00 a.m. revealed four cutting boards that were heavily scored and stained. On 10/8/19 at 10:00 a.m., kitchen staff were observed using cutting boards to cut vegetables, bread and fruit. C. Staff Interview The dietary manager (DM) was interviewed on 10/09/19 at 12:50 p.m. The DM looked at the stains on all the cutting boards and said, I could see the deep scratches being a possible…

    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 · D2019-10-10 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to inform one (#135) of three residents reviewed for liability notices and beneficiary appeal rights of 18 sample residents, both orally and in writing in a language that the resident understood, of their rights. Specifically, the facility failed to provide Resident #135 or their representative a notice of discharge from Medicare services, ensuring acknowledgement of their rights to appeal the discharge. Findings include: I. Notice of non-coverage regulatory reference The Notice of Medicare Provider Non-Coverage (form CMS-10123) letters, also called Non-Coverage letters, Expedited Appeal Notice (ABN), or a Generic Notice, are provided to residents receiving skilled nursing facility (SNF) services funded through Medicare benefits. Non-Coverage letters document that residents and/or their legal representatives have received written notification that discontinuation of Medicare coverage is imminent. II. Record review On 10/8/19 at 10:21 a.m., the social services director (SSD) provided requested copies of the liability…

    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 · D2019-10-10 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to refer one (#4) of one resident reviewed of 18 sample residents to the appropriate state-designated authority for level II preadmission screening and resident review (PASARR) evaluation and determination for services. Specifically, the facility failed to update a PASARR level II for the use of lamotrigine (a mood stabilizer) and for a patient health questionnaire (PHQ-9) score of 12 out of 27. Findings include: I. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included unspecified mood affective disorder and major depression. According to the 10/7/19 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had moderate depression, scoring 12 of 27 on the PHQ-9. The resident had no behavioral symptoms. The resident had little interest or pleasure in doing…

    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 · Dcited before2019-10-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, their comprehensive, person-centered care plan and the resident's choice for one (#133) of one resident reviewed for quality of care of 18 sample residents. Specifically, the facility failed to ensure donning of Geri sleeves per physician's orders. Findings include: I. Resident status Resident #133, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease, macular degeneration, dementia and diabetes mellitus. According to the 9/25/19 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The MDS documented the resident's cognitive skills for daily decision making were severely impaired. She required extensive assistance for bed mobility, transfers, grooming and toilet use. II. Record…

    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 before2019-10-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with the comprehensive person-centered care plan and the residents' goals and preferences for two (#26 and #4) of three residents reviewed for oxygen therapy out of 18 sample residents. Specifically, the facility: -Failed to ensure oxygen was delivered at the ordered liter flow for Resident #26; and -Failed to ensure Resident #4 had a physician's order for the use of oxygen. Findings include: I. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included hypoxemia, shortness of breath, and chronic obstructive pulmonary disease (COPD). The 8/16/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident received…

    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 · D2019-10-10 · 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 observation, interviews, and record review, the facility failed to monitor and document behaviors to prevent behavioral difficulties for three (#4, #132, and #24) of five residents reviewed for behaviors of 18 sample residents. Specifically, the facility failed to: -Monitor and document behaviors and outbursts for Resident #4; -Monitor and document wandering/elopement behaviors for Resident #132; and -The facility failed to effectively track and care plan individualized interventions for Resident #24 who had a diagnosis of dementia. Findings include: I. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included muscle weakness, paroxysmal atrial fibrillation, chronic viral hepatitis, unspecified intracranial injury with loss of consciousness, chronic respiratory failure with hypoxia, and major depression. According to the 10/7/19 minimum data set (MDS) assessment, the resident had no cognitive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-10 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 person-centered dementia care services to two (#26 and #21) of five residents reviewed of 18 sample residents. Specifically, the facility failed to develop and implement person-centered interventions so Residents #26 and #21 could reach their highest practicable quality of life. Findings include: I. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and anxiety disorder. The 8/16/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident was identified as having verbal outbursts in the previous one to three days from the date of the evaluation. The verbal outbursts disrupted care, affected the living environment, and put others at risk…

    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
  • No harm found · C2024-02-08 · tag F0574 — widespread
    The resident has the right to receive notices in a format and a language he or she understands.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to post a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies and advocacy groups. Specifically, the facility failed to post a list of names, addresses, and telephone numbers of all pertinent state agencies, such as the State Survey Agency and the Office of the State Long-Term Care Ombudsman program. Findings include: I. Resident interview The resident council president, Resident #3, was interviewed on 2/6/24 at 3:13 p.m. She said she did not know where the facility posted contact information for State Agencies or the Ombudsman. The contact information and resident rights had been taken down approximately four months ago. II. Observations Observations on 2/5/24, 2/6/24, and 2/7/24 revealed there were no posting of names, addresses (mailing and email) and telephone numbers of pertinent State Agencies. There was no posting of the Ombudsman information. III. Interviews The nursing home administrator (NHA) was interviewed on 2/6/24 at approximately 4:00 p.m. The NHA said…

    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

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$37,103 in federal fines across 2 penalties.

  • $9,110 — penalty dated 2025-12-10
  • $27,993 — penalty dated 2024-02-08

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 CENTENNIAL HEALTHCARE — 8 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 →

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 7 homes this chain runs (chain average 2.4★, per CMS)

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 / managerTypeRoleShareSince
CENTENNIAL II COLORADO HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2024
CENTENNIAL YF TRUST IOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/01/2024
CENTENNIAL II TBD HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2024
CENTENNIAL MN TR IOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/01/2024
SNARL FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2024
GOTTLIEB, REFOELIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 05/01/2024
GOTTS CONSULTING COLORADO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
DEACON, ALICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2024
PANDIT, KIRANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
CENTENNIAL MS TRUST IOrganizationADP OF THE SNFsince 05/01/2024

CMS files one row per role, so the 18 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$2.8M
Net patient revenuemost recent cost report
-21.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 82%Medicare 6%Other / private 12%

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$376per resident / day
operating cost
$11,426per month
≈ monthly operating cost
$309per day
avg. revenue, all payers

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

What families pay in CO

Paying with Medicaid

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.

Typical monthly cost in Colorado
$10,159/mo
Nursing home (semi-private)
$12,182/mo
Nursing home (private)
$6,584/mo
Assisted living

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 065291. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-20, 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.

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