Malley Transitional Care Center

Location & what’s nearby

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

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

Quality measures — how residents actually fare

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

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

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

42.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 79.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 29 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.38 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 162 beds and averages 136.6 residents a day — about 84% occupied, or roughly 25 beds typically open. It usually has some room. 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.89 hrs/resident/day on weekends vs 3.54 on weekdays — 18% thinner on weekends. RN hours go from 0.80 to 0.59 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 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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 15 most serious are shown; the remaining 14 are one tap away and print in full.

• Immediate jeopardy · Kcited before2023-03-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. This was evidenced by hazardous hot water temperatures in resident care areas on two of three units. Water temperatures in resident rooms and two shower rooms exceeded safe temperatures, creating the likelihood for serious harm/injuries if the situation was not corrected immediately. Findings include: I. Immediate jeopardy A. Situation for immediate jeopardy Excessively high water temperatures were discovered in several resident rooms. The facility did not have a system to quickly identify elevated water temperatures in resident rooms, did not measure shower room water temperatures, did not provide education to staff to adjust mixing valves in shower rooms, and did not accurately document resident room water temperatures in order to identify problematic trends and to review and analysis through the quality assurance performance improvement process.…

  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 before2026-05-14 · 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 one (#4) of three residents reviewed for accidents out of 18 sample residents remained as free from accidents and hazards as possible.Resident #4, who had diagnoses of multiple sclerosis (a progressive neurological condition), polyneuropathy (a disease featuring weakness, numbness and burning pain) and anxiety disorder (an intense, excessive and persistent worry and fear about everyday situations), was admitted to the facility on [DATE]. Resident #4 was dependent on staff for transfers utilizing a Hoyer lift (mechanical lift).On 4/7/26 staff were transferring Resident #4 using the smaller Hoyer lift. According to the resident's weight, the resident required the larger Hoyer lift. The resident began to fall and was lowered to the ground.On 4/9/26 at 9:00 p.m. certified nurse aide (CNA) #2 and CNA #3 were transferring Resident #4 from his motorized wheelchair to his bed using a Hoyer lift. During the transfer the sling attached to…

  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 before2023-09-07 · 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 (#2) of three residents reviewed for accidents remained free from accidents. On 7/7/23 Resident #2 sustained an arm fracture during a transfer by one certified nurse aide (CNA) using a sit to stand lift. Prior to the transfer, Resident #2 was not evaluated and was not deemed safe or appropriate for the use of sit to stand lift. The incident during transfer was not clearly communicated to the nurse and head to toe assessment was not completed. As a result, the resident's arm fracture went unnoticed for the next 48 hours. The next day on 7/8/23 the resident refused to be transferred with a sit to stand lift and stayed in bed more than usual. The facility staff used a Hoyer lift for resident transfers for the next two days, however, the nursing staff did not complete a full body assessment to identify the cause of resident's sudden decline. On 7/9/23 the arm fracture was confirmed by the x-ray technician and the resident was sent 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-03-30 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to prevent a significant medication error for one (#85) resident of eight residents reviewed for medication errors out of 47 sample residents. The facility failed to ensure medications were labeled according to the physician's orders to prevent significant medication errors for Resident #85. On 1/6/23, the facility administered 65 mg of Methadone instead of 15 mg ordered on 12/2/22. After the incorrect dose was administered, the resident required Narcan (to treat narcotic overdose) to be administered and was sent to the emergency room. The medication error caused the resident to be upset; he rocked in his wheelchair, hyperventilated, yelled and cursed at staff. Findings include: I. Facility policy and procedure The Medication Errors and Adverse Reactions policy, revised January 2022, was provided by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It revealed in pertinent part, medication error means the observed or identified preparation or…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2019-11-12 · 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 interviews the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by severe or significant weight loss for one (#65) of five residents reviewed for nutrition out of 50 sample residents. Specifically, the facility failed to reassess Resident #65's nutritional status after he removed his gastrostomy tube (G-tube) and experienced a significant weight loss of 19.2% in six months. I. Facility policy and procedure The facility Nutrition Assessment Policy, revised December 2011, was provided by the nursing home administrator (NHA) on 11/12/19. It read, in pertinent part, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current initial assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. The…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-14 · 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 residents were kept free from abuse for one (#14) of five residents reviewed for abuse out of 18 sample residents.Specifically, the facility failed to protect Resident #14 from physical abuse by Resident #10.Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 5/14/26 at 1:45 p.m. It read in pertinent part, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving…

  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 · E2024-09-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to 1.) maintain a comfortable temperature for residents in their rooms and hallway for two of three units (West unit and the East unit), and 2.) maintain the residents' wheelchairs in a condition that was in good repair. Specifically, the wheelchair arms for seven of 78 residents' wheelchairs (Resident (R) 64, R239, R8, R240, R1, R118, and R117) were cracked and missing vinyl exposing the white material underneath. This failure prevented the cleaning and sanitizing of the wheelchair arm rests. Findings include: 1. a. Interview on 09/23/24 at 12:03 PM, R24 stated that her room gets hot and that she needs to use her fan. She stated that the room is not air conditioned (AC) and that the AC was in the hallway. Review of R24's electronic medical record (EMR) Care Plan tab revealed R24's annual Minimum Data Set (MDS), with an assessment referent date of 06/20/24, indicated a Brief Interview of Mental Status (BIMS) score of 14 out 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-26 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure allegations of abuse were reported per the federal regulations to the Colorado Department of Public Health and Environment (CDPHE) within two hours of the facility being made aware of the abuse allegations for three of three residents (Residents (R) 61, R237, and R387) reviewed for allegations of abuse out of a total sample of 31. Findings include: Review of the facility's policy titled, Abuse: Prevention of and Prevention Against, revision date of 10/2022, revealed, . Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to appropriate State or Federal agencies in the applicable timeframes . and applicable regulations . 1. Review of R61's undated Face Sheet, located in the electronic medical record (EMR) under the Profile tab, indicated R61 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety…

  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 · D2024-09-26 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure two of two residents and their representatives (R) 86 and R109) reviewed for facility initiated emergent hospital transfer from a total sample of 31 residents were provided with written transfer/discharge notices that contained the required information. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and how to notify the State Long-Term Care (LTC) Ombudsman's office. Findings include: 1. Review of R86's electronic medical record (EMR) Progress Notes in the Progress Notes tab revealed, . 03/11/24 at 3:48 AM, Resident . reported that he wasn't feeling well . BP [blood pressure] was 123/72, HR [heart rate] 132 Temp [temperature] 101.3 O2 [oxygen] 75% on 5L [5 liters] resp [respirations] 28 . orders to send to ER [emergency room] . Paramedics took resident to [hospital] . Review of R86's EMR Progress Notes in the Progress Notes tab indicated, . 03/13/24 at 11:32 PM, res [resident] back from the hospital…

  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 · D2024-09-26 · tag F0637 — isolated
  Assess the resident when there is a significant change in condition
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one of one resident (Resident (R) 121) reviewed for hospice in a total sample of 31 residents. This had the potential to cause unmet care needs for R121. Findings include: A review of R121's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 09/27/23 with medical diagnoses including stage IV sacral pressure ulcer and osteomyelitis of the vertebra, sacral and sacrococcygeal area. A review of R121's Order Summary Report, located in the resident's EMR under the Orders tab, revealed the following order, dated 04/07/24: admitted to [Hospice Name Withheld] with diagnosis of Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. A review of R121's EMR revealed a quarterly MDS, with an Assessment Reference Date of 06/18/24 and located in the MDS tab of the EMR, which documented the resident was receiving hospice services. A significant change in status MDS was not completed until 07/03/24.…

  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 before2024-09-26 · 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 observation, interview, record review, and review of facility policy, the facility failed to secure one of two medication carts on the East Wing when out of the site of the nursing staff. This failure could permit individual unauthorized access to residents' medications. Findings include: A review of a facility document titled, Medication Access and Storage, E kit access, with a revision date of 04/2024 read in part, Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observation on 09/25/24 at 4:47 PM revealed the medication cart on the East wing was left unlocked at the nurses' station. There were no staff members present at the nurses' station. Residents (R) 8 and R22 were around the unlocked medication cart. R8 sat in a wheelchair across from the cart, and R22 propelled herself up next to the cart. Registered Nurse (RN) 3 returned to the unit and went to…

  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 · Dcited before2024-09-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policy, the facility failed to 1.) follow current standards of practice related to the use of personal protective equipment (PPE) with transmission-based precautions and/or implement their policy and procedures related to enhanced barrier precautions (EBP) for two of two residents (Resident (R) 107 and R389) reviewed for transmission-based precautions out of a total sample of 31, and 2.) sanitize glucometers in a manner that prevented cross-contamination for one of three residents (R76) observed receiving fingerstick blood glucose tests (FSBG). These failures had the potential to lead to the spread of infection throughout the facility. Findings include: Review of the facility's policy titled, IPCP Standard and Transmission-Based Precautions, revised 03/2024, revealed, Droplet Precautions (TBP) are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-03-30 · 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 staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically the facility failed to: -Ensure holding temperatures were at appropriate temperatures; -Ensure proper food handling practices; -Ensure health shakes were dated when thawed; -Ensure artificial nails with polish were not worn by food worker; and, -Ensure meat was thawed correctly. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food-borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding…

  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 · F2023-03-30 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident safety. Findings include: I. Cross-reference citations Cross-reference F689: The facility failed to keep residents free from accident hazards for unsafe hot water temperatures. Cross-reference F880: The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for medication pass, housekeeping, and hand hygiene before meals. II. Facility policy The Quality Assurance and Performance Improvement policy, revised January 2022, was provided by the…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-03-30 · tag F0574 — pattern
  The resident has the right to receive notices in a format and a language he or she understands.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of the State Agency in the facility. Findings include: I. Resident group interview The resident group interview was conducted on 3/30/23 at 3:00 p.m. The group consisted of five alert and oriented residents selected by the facility. All five residents (#61, #45, #72, #85 and #56) said they did not know where the facility posted information in regardS to State Agency contact information, nor did they know how to contact the States Agency. II. Observations Observations, on 3/30/23, throughout the building revealed there was no posting which informed resident's how to contact the State Agency.

  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.

Fines & penalties

$11,180 in federal fines across 1 penalty.

• $11,180 — penalty dated 2023-09-07

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 THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 83% 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. This home reported $1.7M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

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

What families pay in CO