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Crowley County Nursing Center

401 Idaho Ave, Ordway, CO 81063 · Non profit - Corporation · 44 certified beds · (719) 267-3561 Medicare & Medicaid certified

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Resident-funds citation (F0565)1 immediate-jeopardy citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 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
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
319 Main St · (719) 267-3503 · Call to confirm hours
Pharmacy
228 Main St · (719) 267-3411 · Call to confirm hours
Grocery
Kj Foods0.4 mi
207 Main St · (719) 267-3593 · Call to confirm hours
Park
500 Main St · (719) 267-3134 · Typically dawn to dusk
Place of worship
Ordwayumc0.4 mi
403 Main St · (719) 267-4488

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

Quality measures — how residents actually fare

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

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 3 to 4 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 rating4★
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 increased4.1%13.4%15.4%better
Long-stay residents who lose too much weight3.2%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.7%1.4%2.0%better
Long-stay residents with depressive symptoms5.8%8.8%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.4%3.4%3.3%typical
Long-stay residents whose ability to walk worsened4.7%13.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.7%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine97.5%94.7%95.3%typical
Long-stay residents with pressure ulcers0.0%3.4%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control7.5%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table21.9%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 days1.721.381.67typical
Long-stay outpatient ER visits per 1,000 resident days2.531.741.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. 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.

9.6%U.S. median 10.7%
Went back to hospital
0.28U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
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 SNF9.6%CMS range 5.9–14.910.7%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 SNFs1.301.02Oct 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

0.73
RN hours/ resident / day
0.65
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.44
RN hoursweekends
46.8%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 44 beds and averages 37.4 residents a day — about 85% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.14 hrs/resident/day on weekends vs 3.76 on weekdays — 17% thinner on weekends. RN hours go from 0.84 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

7
deficiencies at the latest standard inspection (2024-02-27)
7
at the previous standard inspection (2019-10-11)

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

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.

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.

18 citations, most serious first. The 12 most serious are shown; the remaining 6 are one tap away and print in full.

  • Immediate jeopardy · J2019-10-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to take timely and sufficient steps to implement interventions to prevent the development of pressure injuries, affecting one (#29) out of one resident reviewed for pressure injuries out of 29 sample residents. Resident #29 admitted to the facility with a stage 2 pressure ulcer to her left buttock and was identified as being at risk for pressure ulcer development related to multiple comorbidities including post-polio syndrome, adult failure to thrive, spinal stenosis, and fibromyalgia. Record review revealed Resident #29's pressure ulcer to her left buttock healed over three times. The facility failed to have a system in place to identify and review residents at risk for pressure ulcer development and pressure ulcer re-development. As a result, the facility failed to put appropriate interventions in place timely for Resident #29, which contributed to the development of a pressure ulcer. She developed a pressure ulcer to her coccyx which…

    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 · G2019-10-11 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, 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 systemic issues in its management for residents at risk for pressure ulcers to ensure they were consistently reviewed and appropriate interventions implemented to prevent the redevelopment of pressure ulcers; -Ensure residents were reviewed consistently as an interdisciplinary team (IDT) to prevent unintended weight loss and activities of daily living (ADL) decline; -Perform proper hand hygiene prior to, during, and after wound care treatment; -Ensure clinical signs and symptoms (s/s) of an infection were identified and culture and sensitivity (C&S) were obtained prior to the start of an antibiotic; and -Ensure the dietary department followed…

    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 · F2024-02-27 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and staff interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure a backflow prevention device was installed on the hand held shower hose in the shower room on B hall, increasing the risk of contamination to the facility's main water supply; and, -Ensure necessary kitchen equipment was maintained in safe, sanitary and working condition. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Distribution System Water Quality Protecting Water Quality through Cross-Connection Control and Backflow Prevention, October 2021 retrieved online 2/27/24 from: https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection,…

    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 · E2024-02-27 · tag F0730 — pattern
    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 four of four certified nurse aides (CNAs) reviewed. Specifically, the facility failed to: -Provide inservice education plans based on the outcome of the performance reviews for CNA #2, #3, #4, and #5; and, -Ensure CNAs received 12 hours of training annually for CNA #2, #3 and #4. Findings include: I. Record review CNA #2 (hired 5/2/14) had a performance review on 7/11/23 with eight hours of training. CNA #3 (hired 1/5/22) had a performance review on 3/5/23 with 11 hours of training. CNA #4 (hired 4/16/21) had a performance review on 4/12/23 with 8.5 hours of training. CNA #5 (hired 1/31/23) had a performance review on 4/12/23. -None of theThe CNAs weredid not provided withhave an inservice education plans based on the outcome of their performance reviews. II. Interview The director of nursing (DON) was interviewed on 2/26/24 at 11:20 a.m. She said the facility…

    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 · E2024-02-27 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for four of four CNAs reviewed. Specifically, the facility: -Failed to ensure CNAs #2, #3, #4, and #5 received annual dementia management training; and, -Failed to ensure CNAs #2, #3, and #4 received annual abuse training. Findings include: I. CNA training records review Four CNAs were reviewed for the annual required abuse and dementia management training. -Training records revealed four of the four CNAs did not have dementia training and three of the four CNAs did not have abuse training. CNA #2 was hired on 5/2/14. He had not had annual abuse or dementia management training in the past 12 months. CNA #3 was hired on 1/15/22. She had not had annual abuse or dementia management training in the past 12 months. CNA #4 was hired on 4/16/21. She had not had annual abuse or dementia management training in the past 12 months. CNA #5 was hired on 1/31/23. She had not had annual dementia…

    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 · D2024-02-27 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for two (#25 and #30) of five residents reviewed for unnecessary medication of out 17 sample residents. Specifically, the facility failed to ensure consents were obtained for the usage of psychotropic medications for Resident #25 and Resident #30. Findings include: I. Facility policy and procedure The Psychotropic Medication policy and procedure, which was undated, was provided by the nursing home administrator (NHA) on 2/26/24 at 11:09 a.m. It revealed in pertinent part, Residents, families, and/or representatives are involved in the medication management process. Psychotropic medication management includes: indications for use, dose, duration, and adequate monitoring for efficacy and adverse. II. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included major depressive…

    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 · D2024-02-27 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#25) of three residents reviewed for PASRR out of 17 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #25. Findings include: I. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included major depressive disorder, dementia and anxiety. The 10/27/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment revealed the resident had been identified as having a level II PASRR. II. PASRR level II…

    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 · D2024-02-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for one (#23) of 12 residents reviewed for activities of daily living (ADL) out of 17 sample residents. Specifically, the facility failed to revise Resident #23's person-centered, resident-specific care plan to addressed the resident's refusal of a physician ordered one-on-one for meal supervision. Findings include: I. Resident #23 Resident #23, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included hemiplegia following a cerebral infarction (stroke), contracture of right hand and aphasia (communication deficit). The 1/8/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status…

    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 · D2024-02-27 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#38) of two residents receiving hospice services. Specifically, the facility failed to orient hospice aides to the facility, including the policies and procedures. Findings include: I. Facility policy The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/26/24. It read in pertinent part, Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. II. Resident status Resident #38, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included congestive heart failure and hypertension. 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 · Fcited before2019-10-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews, the facility failed to ensure food was served under sanitary conditions during meal services. Specifically, the facility failed to ensure: -Prevention of potential cross-contamination of food contact surfaces; and -Appropriate use of gloves when handling ready-to-eat foods. Findings include: I. Failure to prevent potential cross-contamination of food contact surfaces A. Professional references The Food and Drug Administration (FDA) Food Code (2017) pp. 49-50, detailed the following instances when foodservice staff should wash their hands: -Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service articles; -After touching bare human body parts other than clean hands and clean, exposed portions of arms; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -When switching between working with raw food and working…

    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 · D2019-10-11 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 prompt efforts to resolve all resident grievances. Specifically, the facility failed to ensure: -Call light wait times were resolved for Resident #35; and -Call light wait times were resolved for a group of individual residents. Findings include: I. Facility policies 1. The Call Light policy, dated 9/8/19 was provided by the social services director (SSD) on 10/9/19. It read, in pertinent part, The director of nursing (DON) or designee will complete a monthly audit to include: regular call light is answered within 5-7 minutes, bathroom call light is answered with 5-7 minutes, resident confirms call light is answered timely. The purpose of this audit is to be able to provide continuing education to all facility staff on the importance of answering call lights in a timely manner to improve overall quality care. 2. A copy of the undated Grievance policy was provided by the SSD on 10/9/19. It read, in pertinent part, The facility has designated its…

    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 · D2019-10-11 · 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 significant weight loss for one (#4) of two residents reviewed for nutrition of 29 sample residents. Specifically, the facility failed to: -Follow the dietary consultant's recommendation to increase a supplement if Resident #4 had continued weight loss; -Notify the physician timely of Resident #4's continued weight loss; -Consistently review Resident #4's significant weight loss as an interdisciplinary team; and -Implement additional nutritional interventions which contributed to Resident #4's unintended weight loss and further activities of daily living (ADL) decline. Findings include: I. Facility policy The Dietary Response to Weight Loss/Gain policy, undated was provided by the director of nursing (DON) on 10/9/19 at 5:30 p.m. It read, in pertinent part, the Dietary Manager will monitor 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
Show the remaining 6 citations
  • Potential for harm · D2019-10-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: -Perform proper hand hygiene prior to, during, and after wound care for Resident #29. Findings include: I. Professional reference According to Centers for Disease Control (CDC) Control and Prevention, Hand Hygiene Basics, retrieved from: http://www.cdc.gov/handhygiene/Basics.html (2019), It read in pertinent part, Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). II. Facility policy The Hand Washing Protocol for Nursing/CNA…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-11 · tag F0881 — failed to use antibiotics responsibly — isolated
    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 staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#18) of one residents out of 29 sample residents. Specifically, the facility failed to: -Ensure clinical signs and symptoms of an infection were identified for Resident #18 prior to administering antibiotics; and -Report culture and sensitivity (C&S) results timely to the physician. Findings include: I. Professional reference According to the CDC, The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A, https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-a.pdf, Communication tools used to facilitate information when a resident is suspected of having an infection should include key pieces of the clinical history including new symptoms and complaints, physical exam findings (e.g.,vital signs, pulse oximetry, localizing pain, etc.) and other relevant…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2018-09-12 · 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 record review, observations and interviews, the facility failed to maintain food at safe temperatures. Specifically, the facility failed to ensure: -Cooked foods were cooled to a safe temperature within established time limits; -Foods meant to be served cold were cooled to an appropriate temperature before service; and, -Hot foods were held or reheated to a proper temperature during meal service. Findings include: I. Professional references According to Colorado Retail Food Establishment Rules and Regulations (CRFERR), March 2013, page 39, The temperature of potentially hazardous foods (time/temperature control for safety foods) shall be 41°F (5°C) or below or 135°F (57°C) or above, at all times, except during necessary periods of preparation or as otherwise noted . According to the March 2013 CRFERR, page 43, Cooked potentially hazardous foods (time/temperature control for safety foods) shall be cooled from 135°F (57°C) to 41°F (5°C), or below, in 6 hours, provided that the food is cooled from 135°F (57°C) to 70°F (21°C) within the first 2 hours. According to the United…

    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 · F2018-09-12 · 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, record review and interviews, the facility failed to maintain and effective pest control program to ensure the environment was free of pests. Specifically, the facility failed to take adequate measures to eradicate and control flies in four of four resident halls and one of one dining rooms to include Residents #9, #7, #31, #19, #3, #13. Findings include: I. Professional references A. 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: 1. Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects should be kept out of all areas of a health-care facility. 2. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Excluding pests from entering the indoor environment and -Applying pesticides as needed. B. According…

    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 · E2018-09-12 · 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 respond to concerns identified and discussed during resident council meetings regarding nursing and maintenance services. Findings include: Cross-reference F925, failed to ensure an effective pest control program was in place. I. Facility policy The activity director (AD) was asked for a policy regarding resident council on 9/10/18 at 2:42 p.m. The AD provided a policy regarding resident council on 9/12/18 at 10:30 a.m. The document, dated 9/12/18, read it was the facility's policy to implement a resident council meeting, convened for approximately one hour on a monthly basis, to discuss and document resident issues and review resident's rights. The facility would also share resident council meeting minutes with department heads for immediate resolution of resident issues. II. Failure A Resident council interviews Resident #9, #19, #3, #13 and #7, regular attendees at resident council meetings, were interviewed on 9/11/18 at approximately 5:00 p.m. The residents said the resident council met once a month. Resident #9 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
  • Potential for harm · E2018-09-12 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the accuracy of advance care planning and provide for periodic review for four (#4, #7, #14 and #28) out of four residents reviewed for advance directives out of 24 sample residents. Specifically, the facility failed to: -Ensure medical orders for scope of treatment pertaining to advance directives were reviewed periodically or upon changes in condition for Resident #s 4, 14 and 28. -Ensure instructions to carry out advance directives were consistent between written and electronic health records for Resident #4 and #7. Findings include: 1. Review of advance directives Resident wishes for advance directives were recorded by the facility on the Colorado Medical Orders for Scope of Treatment (MOST) form. The form was comprised of a section for cardiopulmonary resuscitation (CPR), a section for medical interventions (including instructions for the use of medications, oxygen, suction/airway/intubation and other life sustaining treatment) a section…

    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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
SUMMERS, JEREMYIndividualCONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICERsince 01/05/2023
ARBUTHNOT, BLAINEIndividualCORPORATE OFFICERsince 11/24/2004
NEELY, JERRYIndividualCORPORATE OFFICERsince 11/24/2004

CMS files one row per role, so the 4 rows in the source record cover these 3 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.

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.

$4.4M
Net patient revenuemost recent cost report
+6.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 74%Medicare 4%Other / private 22%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$300per resident / day
operating cost
$9,111per month
≈ monthly operating cost
$320per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CO

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 065312. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-27, 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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