Center At Lincoln, Llc, The
12230 Lioness Wy, Parker, CO 80134 · For profit - Limited Liability company · 96 certified beds · (720) 214-7777 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Nov 2024
- it has 1 actual-harm citation
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.6% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.2% | 20.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.0% | 12.1% | 12.0% | better |
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.
50.8% 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 518 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.1% 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 176 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 1.14 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.8%CMS range 46.6–55.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.6–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 4.0–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 96 beds and averages 80.5 residents a day — about 84% occupied, or roughly 16 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 4.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.07 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.41 hrs/resident/day on weekends vs 5.05 on weekdays — 13% thinner on weekends. RN hours go from 1.13 to 0.90 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2025-11-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of five residents reviewed for accidents out of five sample residents.Resident #1 was admitted on [DATE] for postoperative left knee replacement rehabilitation services and physical therapy. Resident #1 was determined to be a high fall risk related to her postoperative status and history of falls. On 10/17/25 Resident #1 sustained an unwitnessed fall when she was left unattended in the bathroom.On 10/24/25 Resident #1 sustained an additional fall when she was left unattended in the shower. She sustained a left femur fracture that was deemed inoperable for repair. Specifically, the facility failed to ensure fall interventions were consistently implemented for Resident #1, which resulted in a fall with major injury. Findings include:I. Facility policy and procedureThe Fall Prevention policy, revised 7/24/23, was provided by the nursing home administrator (NHA)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-21 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure foods were appealing and palatable in temperature and seasoning. Findings include: I. Facility policy and procedure The Food Palatability policy and procedure, revised 8/22/22, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, Food and drink each resident receives and the facility provides foods prepared by methods that conserve nutritive value, flavor, and appearance. In addition, the food is palatable, attractive, and served at a safe and appetizing temperature. The dietary staff prepares foods according to the menu and recipes available in the dietary department. Foods are sampled daily by designated staff to ensure the taste and quality of the foods remain at a high level. Use of seasonings and proper cooking methods are followed to ensure the food is appealing and palatable. II. Resident interviews Resident #221 was interviewed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen; and, -Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators. Findings include: I. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 11/25/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-21 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 develop an acute/baseline care plan for four (#380, #376, #382 and #225) of four residents reviewed for baseline care plans out of 60 sample residents. Specifically, the facility failed to ensure Resident #380, #376, #382 and #225 were provided a copy of their baseline care plan with 48 hours of admission to the facility. Findings include: I. Facility policy and procedure The Baseline Care Plan policy and procedure, revised March 2020, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part, It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident. The care plan will identify priority problems and needs to be addressed 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.
- Potential for harm · E2024-11-21 · tag F0660 — patternPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to develop and implement an effective discharge plan for nine (#376, #378, #380, #371, #388, #382, #10, #185 and #225) of 10 residents reviewed for discharge planning out of 60 sample residents. Specifically, for Residents #376, #378, #380, #371, #388, #382, #10, #185 and #225, the facility failed to: -Ensure residents and their representatives were involved in the development of the discharge plan; -Ensure the discharge plan of care was updated with the residents' discharge goals; and, -Ensure the discharge planning process was documented in the residents' electronic medical records (EMR). Findings include: I. Facility policy and procedure The Admissions, Readmission, Transfers, and Discharge Process policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part, It is the policy of this facility to permit each resident to remain in the facility, and not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-21 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) in COVID-19 positive resident rooms; -Ensure proper infection control practices were followed for wound care; -Identify an effective process to ensure staff were aware of which residents required enhanced barrier precautions (EBP); and, -Ensure staff wore the appropriate PPE for residents on EBP. Findings include: I. Failure to ensure staff wore the appropriate personal protective equipment (PPE) in COVID-19 positive resident rooms A. Professional reference According to the Center for Disease Prevention and Control (CDC) Infection control Guidance: SARS-CoV-2, (9/23/22) retrieved on 11/26/24 from https://www.cdc.gov/covid/hcp/infection-control/, Healthcare personnel (HCP) who enter the room of a patient with suspected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0552 — isolatedEnsure 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 record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#226) of five residents reviewed for unnecessary medications out of 60 sample residents. Specifically, the facility failed to ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained for Resident #226 prior to the administration of a psychotropic medication. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy and procedure, revised 2/8/21, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, Psychotropic consent will be obtained from the resident and or family on admission or within 72 hours of admission. II. Resident #226 A. Resident status Resident #226, age [AGE], was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included adjustment disorder with mixed anxiety and depressed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 honor resident choices for one (#53) of one resident out of 60 sample residents. Specifically, the facility failed to ensure Resident #53's preference to have her bed bath completed during the day shift was honored. Findings include: I. Resident #53 A. Resident status Resident #53, age less than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, bathing, and lower body dressing and was partially dependent on staff for all other activities of daily living (ADL). The assessment indicated that it was very important that she was able to choose between a tub bath, shower, bed bath or sponge bath. B.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 misappropriation of property for three (#228, #46 and #229) of three residents reviewed for personal property out of 60 sample residents. Specifically, the facility failed to prevent the loss of property for Resident #228, Resident #46 and Resident #229 during their time in the facility. Findings include: I. Facility policy and procedure The Dignity policy and procedure, revised 8/15/22, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, Residents' private space and property shall be respected at all times. Staff will not handle or move a resident's personal belongings (including radios and televisions) without the resident's permission. II. Resident #228 A. Resident status Resident #228, age less than 65, was admitted on [DATE] and discharged home on 7/29/24. According to the November 2024 computerized physician orders (CPO), diagnoses included muscle weakness and hypotension (low…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure activities were designed to support residents physical, mental and psychosocial well-being were provided for two (#373 and #36) of two residents out of 60 sample residents. Specifically, the facility failed to identify and meet the socialization needs for Resident #373 and #36. Findings include: I. Facility policy and procedure The Activities policy and procedure, revised February 2024, was received by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part, The resident has the right to choose activities and participate in activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility. The facility will ensure and implement an ongoing resident-centered activity program that incorporates the resident's hobbies and culture preferences, which is integral to maintaining and or improving a resident's physical, mental and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#53) one resident out of 60 sample residents. Resident #53 was admitted to the facility for rehabilitation services on 10/4/24 with a diagnosis of fracture of the left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/5/24 admission skin assessment indicated the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. The assessment did not indicate that the resident had any abdominal wounds. On 10/24/24 the resident was noted to have two facility acquired moisture associated skin disorder (MASD) wounds to her abdominal folds. The facility failed to provide the resident with showers per her preferences. Due to the facility's failures, observations revealed the resident had developed three MASD wounds to her abdomen. Through observations, 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.
Show the remaining 18 citations
- Potential for harm · D2024-11-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#174) of one resident reviewed for pressure ulcers out of 60 sample residents received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure Resident #174's physician ordered heel protection boots were consistently implemented as an intervention to prevent potential pressure wounds. Findings include: I. Professional reference According to the International Wound Journal's Summary of Best Evidence For Prevention and Control Of Pressure Ulcers on Support Surfaces (3/9/23), retrieved on 12/2/24 from https://pmc.ncbi.nlm.nih.gov/articles/PMC10332999/#:~:text=Therefore%2C%20this%20study%20included%20heel,in%20a%20%E2%80%9Cfloating%E2%80%9D%20position.&text=This%20means%20keeping%20the%20heel,risk%20assessment%20in%20the%20future, A pressure ulcer is a localized injury caused by continuous pressure on the skin and/or subcutaneous soft tissues, usually…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#382) of one resident reviewed for pain out of 60 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to ensure Resident #382, who experienced an acute episode of pain, was provided pain relief and had an effective pain management program to address her continuous pain. Findings include: I. Facility policy and procedure The Analgesia policy and procedure, revised August 2022, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It read in pertinent part, Pain management procedure: based on the assessment, the facility, in collaboration with the attending physician, or medical director, and the resident initiated interventions to prevent or manage the resident's pain, beginning at admission. These interventions may be integrated into components…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide pharmaceutical services to meet the needs of one (#1) of three residents out of three sample residents. Specifically, the facility failed to ensure two inhaler medications for Resident #1 were ordered and delivered to the facility as ordered by the physician. Findings include: I. Facility policy and procedures The Medication Ordering From Pharmacy policy, reviewed 4/2/24, was provided via email on 10/9/24 at 1:21 p.m. by the director of nursing (DON). It revealed in pertinent part, The purpose of this policy is to assure that patients receive their medication delivery when admitted to the facility in a timely manner. Standard Process: All medications will be faxed to the pharmacy once the medications have been verified with the provider when a patient admits to the facility or when a new RX (prescription) is received and patient(s) need a medication refill. If medications are on the delivery manifest but were not delivered the provider…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of one kitchens. Specifically, the facility failed to: -Ensure a clean and sanitary kitchen within the dry storage room; around the grill and fryer; within smaller refrigerator units; and surfaces of the kitchen; and, -Ensure open food items were properly labeled with open dates and sealed for storage to prevent contamination. Findings include: I. Professional standards According to The Colorado Department of Public Health and Environment (CDPHE), Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 6/12/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view Persons who are more likely than other people in the general population to experience foodborne disease because they are older adults; and they obtain food at a facility that provides services such as nursing homes. Food Storage.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for six out of six rooms. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles, phone and hand rails); -Ensure surface disinfectant times were followed; and, -Ensure staff followed personal protective equipment (PPE) precautions for a resident diagnosed with COVID-19 when providing care and when cleaning the resident room. Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-06 · tag F0585 — failed to handle grievances — patternHonor 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 observations and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents. Specifically, the facility failed to: -Follow up and document Resident #33's grievance reported to a staff member; and, -Ensure residents were aware how to file a grievance and place grievance forms in prominent locations throughout the facility. Findings include: I. Facility policy The Grievance policy, last revised on 2/8/21, was provided by the director of nursing (DON) on 6/6/23 at 5:30 p.m. it read in pertinent, Grievances can be communicated to a staff member either verbally or in writing. All patients will be informed of the location of the facility's grievance forms should they wish to write a formal complaint. Any patient who wishes to do so may express his/her grievances in writing or verbally to any staff member; however, they are strongly encouraged to express the complaint (s) directly to Social Services, Executive Director, or the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-06 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for three residents (#226, #232 and #236). Specifically, the facility had a medication error rate of 7.89 percent, which was three errors out of 38 opportunities for error. Findings include I. Professional reference and manufacturer recommendations According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 6/12/23, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-06 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for three residents (#226 #232 and #236) of four reviewed for medication administration out of 44 sample residents. Specifically, the facility failed to ensure insulin pens were primed prior to medication administration for Residents #226, #232 and #236. Cross-reference F759 failure to ensure the medication error rate was less than five percent. Findings include: I. Professional reference According to the Humalog (Lispro) package insert, retrieved 6/12/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf Instructions for use: priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin. According to the Humalin N kwikpen (NPH) instructions for use, retrieved on 6/12/23 from:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards on two of two units reviewed of four units. Specifically the facility failed to: -Ensure prescribed medications were labeled correctly; -Remove expired medications from the cart; and, -Ensure topical medications were not stored with oral medications. I. Professional standards According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 608, Medication error often occurs because a patient gets a medication intended for another patient. Therefore, an important step in safe medication administration is being sure that you give the right medication to the right patient. II. Facility policy The Storage of Medications policy and procedure, revised on 2/8/21, received from the director of nursing (DON) on 6/5/23 at 11:29 a.m. revealed in pertinent part, the medication and biological were stored…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-06 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures for all residents. Specifically, the facility failed to ensure resident food was palatable in taste and temperature. Findings include: I. Resident interviews Resident #2 was interviewed on 5/31/23 at 10:26 a.m. Resident #2 said the facility meals were sometimes cold when served, making the meal unappealing. Resident #33 was interviewed on 5/31/23 11:34 a.m. Resident #33 said the facility food was bland; and there was not much variation in the menu. He was served mash potatoes and gravy almost daily. Resident #33 would have liked to have seed potatoes in a different form; there needs to be more variety. Resident #33 said he made certain menu choices and did not get what he ordered; especially when it came to asking for a banana; food often arrived cold when it should have been hot. Resident #33 said he asked for sausages the other day and when the sausage arrived it was cold like it just came out of the refrigerator.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-06 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to implement an effective training program for staff. Specifically, the facility failed to: -Ensure two certified nurse aides (CNA) out of five CNAs reviewed completed the required annual abuse identification, prevention and reporting training; and, -Ensure three CNAs out of five CNAs reviewed completed the required annual dementia care training. Findings include: I. Facility policy and procedure The Facility Assessment policy, revised 12/13/2020, was provided by the nursing home administrator (NHA) on 6/6/23 at 1:15 p.m. It documented in the pertinent part, All staff members complete (computer program) training modules during orientation and prior to beginning on the job training. Additionally, staff complete the training modules annually. These modules included recognizing and reporting abuse and understanding Alzheimer's and dementia. II. Record review The facility provided employee training records on 6/6/23 for five randomly selected CNAs. -CNA #6 and CNA #7 did not have annual abuse identification, prevention and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-09-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 items were stored and served under sanitary conditions for one of one serving areas. Specifically, the facility failed to ensure: --Food temperatures of cold food items were held at the proper temperature to reduce the risk of food borne illness; and --Disinfecting chemicals were maintained at appropriate parts per million (PPM). --Chemical constituents were not making contact with food Findings include: I Inadequate holding temperatures 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 reads in pertinent part; The food shall have an initial temperature of 41 degree Fahrenheit (ºF) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Observation During observations of the noon meal on 9/11/19 beginning at 11:35…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-09-12 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication pass observation error rate was 10%, or three errors out of 30 opportunities for error. Findings include: I. Professional facility reference The reference used by the facility for the medication administration policy was provided by the director of nurses (DON) on 9/12/19. The reference which the policy was based on was from the medical consultants network incorporation. Facility policy The medication administration policy dated October 2017, provided by the director of nurse (DON) on 9/12/19 at 3:00 p.m., read in pertinent part: .It is the policy that medications are to be administered as prescribed by the attending physician. Medications may not be set up in advance and must be administered with one hour after their prescribed time . Observations medication errors Licensed practical nurse (LPN) # 1 was observed to prepare and administer medications to Resident #34 on 9/10/19 at 2:38 p.m. The medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-09-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure infection control practices were followed to prevent the spread of infection. Specifically the facility failed to: -Follow proper handwashing; -Follow proper glove use when working between dirty and clean processes; -Clean equipment between residents; and -Use personal protective equipment (PPE) correctly. Findings include: I.Failed to follow proper handwashing; follow proper glove use when working between dirty and clean processes; -Clean equipment between residents A.Facility policy The infection control precautions policy dated 2/1/16 was provided by the nursing home administrator (NHA) on 9/16/19. It read in pertinent part, The facility was dedicated to provide the best care possible to residents who entrust their care to the facility. All employees would do everything possible to keep infection down. -routine hand washing, used soap, water and friction. Hands were used with alcohol based waterless hand cleaner between washed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to ensure three residents (#173, #182, and #63) out of five were treated with respect and dignity. Specifically, the facility failed to: -Ensure staff addressed concerns about food and medication for Resident #182; -Ensure outside agency staff interacted with Resident #173 who had severe cognitive impairments, in a manner appropriate to his health care needs; and -Provide meaningful interaction with Resident #63 to ensure needs were met. Findings include: I.Facility policy The Dignity policy, revised 10/17, was provided by the nursing home administrator (NHA) on 9/16/19 at 12:00 p.m. It read in pertinent part, The [facility name] will promote care for patients in a manner and in an environment that maintains or enhances each patient's dignity and respect in full recognition of his or her individuality. A.Failed to address concerns about food and medication needs. 1.Resident #182's status Resident #182, age [AGE], was admitted on [DATE]. According 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.
- Potential for harm · D2019-09-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and record review, the facility failed to provide necessary assistance with activities of daily living (ADLs) for two (#276 and #63) of two residents reviewed. Specifically, the facility failed: - to provide timely incontinent care for Resident #276 - to provide meal assistance to Resident #63 Findings include: I. Timely incontinent care A.Resident #276's status Resident #276, age [AGE], was admitted to the facility on [DATE]. According to the September 2019 computerized physician orders (CPO), diagnoses include dysphasia and adult failure to thrive. The 9/11/19 minimum data set (MDS) assessment revealed, Resident #276 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistant with one person for bed mobility, transfers, dressing and toileting. The resident was incontint of bowel. 1. Observations Continuous observation with Resident #276 on 9/11/19 -At 8:15 a.m., the resident was observed to lay in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-12 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview, the facility failed to establish nurses were able to demonstrate the skills and competencies needed to provide peripheral intravenous central catheter (PICC) line care to residents. Specifically the facility failed to: -provide an order to obtain blood from a PICC line -discard blood according to standard during PICC lab draw -ensure LPN #4 had an intravenous (IV) certificate to work on the PICC line Findings include: Facility reference to build the policy The reference used by the facility on the catheter insertion and care policy was provided by the director of nurses (DON) on 9/12/19. The reference used was from the Centers for Disease Control and prevention (CDC). Guidelines for the prevention of intravascular catheter related infections section 25.06 dated September 2010. Facility policy The catheter insertion and care policy revised July 2016, provided by the director of nurses (DON) on 9/12/19 at 3:00 p.m., read in pertinent part: .The purpose of that procedure was to provide guidelines for the safe and aseptic sampling 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.
- Potential for harm · Dcited before2019-09-12 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY II.Failed to follow physician prescribed pain level parameters when administering pain medications to Resident #63. A.Facility policy The Pain Management for Cognitively Impaired Residents policy, dated 5/9/17, was provided by the nursing home administrator (NHA) on 9/12/19 at 4:02 p.m. It read in pertinent part; Purpose is to help staff identify pain in the resident, and to develop interventions to manage resident's pain when resident is cognitively impaired. It is the responsibility of the nursing staff member to evaluate the resident's pain every shift. If the resident has a cognitive impairment, the [name brand] Pain Scale should be utilized. B.Resident #63's status Resident #63, age [AGE], was admitted on [DATE]. According to the September 2019 computerized physician order, diagnoses included dementia without behavioral disturbance, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing The 8/28/19 minimum data set (MDS) documented that 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to VERITAS MANAGEMENT GROUP — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 4.2 | -2.2 vs chain |
| Health inspection | 2 of 5 | 3.7 | -1.7 vs chain |
| Staffing | 4 of 5 | 3.1 | +0.9 vs chain |
| Quality measures | 4 of 5 | 4.8 | -0.8 vs chain |
The other 12 homes this chain runs (chain average 4.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DON QUIXOTE ENTERPRISES, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 09/01/2012 |
| GREENHOW, ROBERT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 09/01/2012 |
| LOUCKS, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 09/01/2012 |
| BARKER, JOHN | Individual | CORPORATE OFFICER | — | since 09/01/2012 |
| MURDOCK, MONTE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2012 |
| VERITAS MANAGEMENT GROUP LLC | Organization | ADP OF THE SNF | — | since 09/01/2012 |
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.
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Colorado Medicaid page for homes that do.
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 065403. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-21, 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.