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Atlas Post Acute

2611 Jones Ave, Pueblo, CO 81004 · For profit - Corporation · 146 certified beds · (719) 564-1735 Medicare & Medicaid certified

Call the home — (719) 564-1735 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 20263 actual-harm citations$39,368 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • 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
  • the CMS record shows $39,368 in federal fines (most recent 2023-11-02)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (65%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS
Urgent care / clinic
1910 Lake Ave · (719) 566-3518 · Call to confirm hours
Pharmacy
1728 S Prairie Ave · (719) 564-0220 · Call to confirm hours
Grocery
3050 W Northern Ave · (719) 564-0590 · Call to confirm hours
Park
(719) 549-7555 · Typically dawn to dusk
Place of worship
2525 Baystate Ave · (719) 553-8759

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-03 to 2026-06, this home’s CMS overall rating improved from 1 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 increased6.0%13.4%15.4%better
Long-stay residents who lose too much weight1.4%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%1.4%2.0%better
Long-stay residents with depressive symptoms13.1%8.8%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%3.4%3.3%better
Long-stay residents whose ability to walk worsened11.8%13.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.1%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine96.6%94.7%95.3%typical
Long-stay residents with pressure ulcers6.7%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control15.3%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table24.2%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 days1.181.381.67better
Long-stay outpatient ER visits per 1,000 resident days3.031.741.80worse

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

10.7%U.S. median 10.7%
Went back to hospital
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 73% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 6.6–16.010.7%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 SNFs0.791.02Oct 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

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
64.6%
Total nursing turnover
80.0%
RN turnover

How full it usually is: this home is certified for 146 beds and averages 73.4 residents a day — about 50% occupied, or roughly 73 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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.

Weekend coverage: total nurse staffing is 3.02 hrs/resident/day on weekends vs 3.44 on weekdays — 12% thinner on weekends. RN hours go from 0.62 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above 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

1
deficiencies at the latest standard inspection (2024-10-22)
4
at the previous standard inspection (2024-04-30)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#2) of four residents reviewed for accidents/hazards out of 29 sample residents. Resident #2, who was admitted on [DATE], required substantial assistance to roll from her back to her right or left side in the bed. On the afternoon of [DATE], certified nurse aide (CNA) #3 elevated Resident #2's bed and then repositioned the resident onto her side to provide incontinence care. Resident #2 rolled off the elevated bed onto the floor during care. Interviews during the survey revealed Resident #2 was communicating with staff prior to the incident, however, Resident #2's responsiveness deteriorated significantly immediately after the fall. Resident #2 said she had head pain after the fall. Resident #2 was transferred to the hospital within an hour of the fall. Resident #2 experienced cardiac arrest while en route to the hospital and expired within 10 minutes of her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-11-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure one (#14) of one residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 39 sample residents. Specifically, the facility failed to ensure Resident #14 was provided with preventative measures to help minimize the development of and the worsening of contractures. Resident #14 had a contracture to his left hand and no preventative measures were implemented. When Resident #14 was assessed during the survey on 10/31/23, his left hand finger contractures worsened and he developed a contracture to his right hand. Findings include: I. Facility policy and procedures The Activities of Daily Living (ADL) Supporting policy, revised in March 2018, was provided by the nursing home administrator (NHA) on 10/30/23 at 8:29 p.m. The policy revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-11-02 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide effective pain management program for two (#53 and #4) of three residents reviewed for pain management out of 39 sample residents. Resident #53 had pain control during a wound dressing change on 10/31/23 at 4:15 p.m. The resident experienced severe pain during the dressing change. The resident was administered a pain medication at 3:40 p.m., although the resident told the nurse that she was in pain, the dressing change continued. The resident was not offered any other type of pain intervention. In addition, the facility failed to for Resident #4: -Have a pain parameters for as needed (PRN) pain medications; and, -Thoroughly assess the resident's pain. Findings include: I. Facility policy The Pain -Clinical Protocol policy, updated October 2022, was received on 11/2/23 at 1:00 p.m. from the nursing home administrator. The policy read in pertinent part, The staff and physician will identify the characteristics of pain such as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-14 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure three (#25, #15 and #18) of seven residents were free from abuse out of 29 sample residents.Specifically, the facility failed to:-Protect Resident #18 from verbal abuse by Resident #17;-Protect Resident #15 from physical abuse by Resident #16; and,-Protect Resident #25 from physical abuse by Resident #24.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised, April 2021, was provided by the nursing home administrator (NHA) on 5/12/26 at 9:00 a.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents.II. Incident of verbal abuse of Resident #18 by Resident #17 on 11/16/25A. Facility investigationThe facility's investigation was provided by the NHA on 5/12/26 at…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · 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 observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries for one (#9) of four residents out of 29 sample residents. Specifically the facility failed to ensure staff consistently provided wound care to Resident #9 in a timely manner, per physician's orders.Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019) retrieved on 5/18/26 from https://www.internationalguideline.com/the-international-guideline, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that did not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#2) of three out of 12 sample residents.Specifically, the facility failed to notify the provider when Resident #2's pain medication was unavailable to be administered. Findings include: I. Professional reference According to PharMerica (undated) Missed Medication Administration retrieved on 2/5/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2022/03/DidYouKnow_Missed-Medications.pdf Suggested steps for potential unavailable meds include: call pharmacy to order medication (faxing is also recommended for reproducible verification, but call for time sensitive medications); consult pharmacy staff to determine the appropriate delivery time (next scheduled delivery, STAT, etc); notify pharmacy of pertinent diagnoses and if any doses have already been missed; document the name of pharmacy staff you…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-05 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of three residents reviewed for medications errors out of four sample residents. Specifically the facility failed to:-Ensure Resident #1 was administered Midodrine (for low blood pressure) per physician's orders and parameters;-Ensure Resident #1 had a blood pressure taken prior to administration of a hypotension medication; and,-Identify and document medication errors.Findings include: I. Facility policy and procedureThe Medication Administration policy, revised April 2019, was provided by the nursing home administrator (NHA) on 10/8/25 at 11:40 a.m. It read in pertinent part, Medications are administered in a safe and timely manner, as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported and reviewed by the quality assurance performance improvement (QAPI) committee to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-22 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for three (#38, #18, #23) of three residents out of 32 sample residents. Specifically, the facility failed to provide food choices according to resident preferences for Resident #38, Resident #18 and Resident #23. I. Facility policy and procedure The Resident Food Preferences policy, revised 2015, was provided by the nursing home administrator (NHA) on 10/22/24 at 4:30 p.m. It read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Nursing staff will document the resident's food and eating preferences in the care plan. II. Resident #38 A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus…

    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 · E2024-04-30 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on two of two medication carts. Specifically, the facility failed to: -Ensure insulin (medication for diabetes) pen injection devices were labeled appropriately with open dates; and, -Ensure inhaler medications were labeled appropriately with open dates. Findings include: I. Professional references According to the Lantus glargine insulin package insert, retrieved 5/6/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, When in use can be kept at room temperature for up to 28 days. According to the Humalog package insert, retrieved on 5/6/24 from https://uspl.lilly.com/humalog/humalog.html#ug, Do not use Humalog past the expiration date printed on the label or 28 days after the first usage. According to the Fluticasone inhaler manufacturer's guidelines, retrieved on 5/6/24 from https://www.advair.com/, Store Fluticasone inhaler in the unopened foil pouch and only open when ready for use. Safely throw away Fluticasone 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 upon observations, interviews and record review, the facility failed to ensure one (#32) of three residents reviewed for assistance with activities of daily living (ADL) received fingernail care out of the 31 sample residents. Specifically, the facility failed to ensure Resident #32's fingernails were trimmed and clean. Findings include: I. Facility policy and procedure The Fingernails/Toenail policy, revised February 2018, was provided by the nursing home administrator (NHA) on 4/30/24 at 1:56 p.m. It revealed in pertinent part, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent residents from accidentally scratching and injuring their skin. II. Resident #32 A. Resident status Resident #32, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#27) of five residents reviewed for unnecessary medications out of 31 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure a resident with a continuous glucose monitor was monitored effectively to include frequency of the glucose monitor changes, training staff on the continuous glucose monitor, and care planning the use of a continuous glucose monitor. Findings include: I. Professional reference According to the Freestyle Libre 2 continuous glucose monitor manufacturer's guidelines, retrieved on 5/1/24 from https://www.freestyle.[NAME]/us-en/safety-information.html, What should you know about wearing a Sensor: -The Sensor can be worn for up to 14 days. -Some individuals may be sensitive to the adhesive that keeps the Sensor attached to the skin. If you notice…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for one (#20) of three residents reviewed for respiratory care out of 31 sample residents. Specifically, the facility failed to ensure Resident #20 received oxygen therapy in accordance with the physician's order. Findings include: I. Facility policy and procedure The Oxygen Administration policy, revised October 2010, was provided by the nursing home administrator (NHA) on 4/29/24 at 1:59 p.m. It revealed in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician' s order for this procedure. Review the physician' s orders or facility protocol for oxygen administration. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. II. Resident #20…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-02 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations 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 three out of three units at the facility. Specifically, the facility failed to: -Ensure residents' personal toiletry items were labeled appropriately; -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure a wound cleanser was placed in an appropriate place; and, -Ensure the staff had knowledge to ensure blood glucose meters were cleaned properly; Findings include: I. Failure to ensure resident toiletry items were marked in shared rooms A. Observations 11/1/23 at 1:30 p.m. -room [ROOM NUMBER] a shared room, had an unmarked comb at the sink. -room [ROOM NUMBER] a shared room, had an unmarked and unbagged urinal in the bathroom. -The 500 hall shower room had a used unmarked deodorant. -room [ROOM NUMBER] a shared room, had…

    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
Show the remaining 16 citations
  • Potential for harm · E2023-11-02 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews the facility failed to provide services for three (#4, #12 and #36) of four reviewed out of 39 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #4, Resident #12 and Resident #36's vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Professional reference Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine.https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 11/8/23. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. Kizior, R. J, [NAME], K. J. (2023).…

    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 · E2023-11-02 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for three licensed practical nurses (LPNs) and and one registered nurses (RNs). Specifically, the facility failed to: -Complete competencies for LPN #1, #3 and #2; and, -Complete competencies for RN #5 Cross-reference F760 failure to identify skill training and competencies for staff education in mathematics calculations for liquid medications. I. Observation On 11/1/23 at 7:35 a.m. licensed practical nurse (LPN) #1 checked Resident #36 ' s oral morphine order on the medication administration record which read Morphine 20 milligrams (mg)/5 milliliters (ml) give 0.25 ml. LPN #1 obtained the oral morphine from the medication administration cart which read 100 mg/5 ml. He then pulled up 0.25 ml of the 100mg/5ml concentration and administered it to Resident #36. II. Competencies The competency files for LPN #1, LPN #2, LPN #3…

    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 · Ecited before2023-11-02 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#36) of four residents reviewed for medication errors of 39 sample residents. Specifically, the facility failed to ensure that Resident #36 was administered the correct dose of oral morphine by verifying the correct concentration of oral morphine on the medication administration record (MAR) with the correct concentration of the oral morphine provided. Findings include: I. Professional reference [NAME], A., [NAME], L. M. (September 5, 2022). Nursing Right of Medication Administration. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK560654/ retrieved on 11/9/23. Right dose-Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct medication 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-02 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#64, #34, #26, #21 and #52) of eight residents reviewed for immunizations out of 39 sample residents. Specifically, the facility failed to: -Offer Resident #64 and #21 the pneumococcal vaccine upon admission; -Offer additional doses of the pneumococcal vaccine to Resident #26 and #34; and, -Offer Resident #52 the pneumococcal vaccine after signing a consent to receive. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 11/5/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate…

    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 · D2023-11-02 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews the facility failed to ensure the right to self administer medications appropriately in one (#34) out of 39 sample residents. Specifically, the facility failed to -Ensure Resident #34 had an evaluation and a physician's order for Resident #34 to self administer eye drops and nasal spray at the bedside; and, -Ensure Resident #34 had a physician's order to self administer inhalers at the bedside Findings include: I. Facility policy and procedure The Self Administration of Medications policy and procedure, reviewed February 2021, was provided by the NHA on 11/2/23 at 1:00 p.m. It read in pertinent part, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT ) assesses each resident's cognitive and physical abilities to determine whether self administering medication is safe and clinically appropriate for the resident. Self administered medications are stored in a safe and secure place, which is not accessible by other residents.…

    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 · D2023-11-02 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 inform residents of the facility's bed hold policy for one (#85) of three residents reviewed for discharge/transfer out of 39 sample residents. Specifically, the facility failed to ensure Resident #85 or their responsible party were informed in writing of the facility's bed hold policy prior to being discharged or transferred from the facility. Findings include: I. Facility policy and procedure The Bed Holds and Returns policy, dated October 2022, was provided by the director of nurses (DON) on 11/2/23. The policy read in pertinent part, All residents/representatives are provided written information regarding the facility and state bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalizations). Residents, regardless of payer source, are provided written notice at least twice: a. Notice 1: well in advance or any transfer (admission packet); and b. Notice 2: at the time of transfer (or if the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · 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 record review and interviews the facility failed to coordinate assessments with the preadmission screening and resident review (PASRR) program for two (#16 and #32) of nine residents reviewed for PASRR out of 39 sample residents. Specifically, the facility failed to: -Ensure a PASRR level II evaluation was available in the medical record of Resident #16 with a known major mental illness; and, -Ensure a PASRR level II evaluation was completed for Resident #32 after the resident was identified as having a known major mental illness. Findings include: I. Facility policy and procedure The PASRR policy and procedure, with no review date, was received by the nursing home administration (NHA) on 11/1/23 at 1:50 p.m. It read in pertinent part: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated…

    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 · D2023-11-02 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to submit a preadmission screening and resident review (PASRR) level I for one (#23) of four residents reviewed for PASRR out of 39 sample residents. Specifically, the facility failed to submit a PASRR level I for Resident #23 who was admitted with a known major mental illness. Findings include: I. Facility policy and procedure The PASRR policy and procedure, with no review date, was received by the nursing home administration (NHA) on 11/1/23 at 1:50 p.m. It read in pertinent part: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions. II. Resident status Resident #23, age…

    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 · D2023-11-02 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 a discharge summary was in place for one (#86) resident out of three sample residents reviewed for discharge out of 39 sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay, a final summary of the resident's status and recapitulation of the resident's stay at the facility for Resident #86. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy, revised October 2022. It read in pertinent part, The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with the established regulations governing release of resident information and as permitted by the resident. II. Failure to complete a complete and thorough discharge summary 1. Resident #86 A. Resident status Resident #86, age [AGE], was admitted on [DATE] and discharged…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (#14 and #53) of three residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure Residents #14 and #53 received assistance with showers as scheduled. Findings include: I. Facility policy and procedures The Activities of Daily Living (ADL), Supporting policy, revised in March 2018, was provided by the nursing home administrator (NHA) #1 on 10/30/23 at 8:29 p.m. The policy revealed, residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out activities of daily living independently, would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. With the consent of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that the resident ' s environment was free from accident hazards for one (#4) of three resident reviewed for falls out of 39 sample residents. Specifically, the facility failed to: -Ensure that fall risk assessments were in place, before and after a fall, for Resident #4 with a history of falls; -Document neurological assessments after Resident #4 fell; and, -Document an interdisciplinary team (IDT) review to establish causative factors of the fall and failed to implement and care plan new interventions. Findings include: I. Facility policy and procedure The Fall Risk Assessment policy and procedure, reviewed March 2018, was provided by the nursing home administration (NHA) on 10/30/23 at 8:29 p.m. read, in pertinent part: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 that a consent and a safety bed rail evaluation was in place for one (#12) of one resident with bed rails out of 39 sample residents. Specifically, the facility failed to: -Failed to obtain a consent for Resident #12 with safety risks versus benefit and alternatives prior to the use of half bed rails; and, -Failed to obtain a safety evaluation for Resident #12 prior to the use of half bed rails. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA). (2023). Recommendations for Health Care Providers Using Adult Portable Bed Rails. https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails, retrieved on 11/8/23 included the following recommendations, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 staff interviews, the facility failed to ensure the mediation error rate was not greater than five percent. Specifically the facility's medication error rate was 7.14% with two errors out of 28 opportunities. Findings include: I. Professional reference [NAME], A., [NAME], L. M. (9/5/22). Nursing Right of Medication Administration. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK560654/ retrieved on 11/9/23. Right dose-incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct medication and the patient's identity is verified, with first checking to ensure it is the correct strength for the patient. Right time-administering medication at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure medical records were kept in a secure and confidential manner and the medical record was complete and accurate in keeping with accepted standards of practice for three (#85, #23 and #53) out of 39 sample residents reviewed. Specifically, the facility failed to ensure: -Resident #85's discharge to the hospital was accurately documented; -For Resident #23 hours of sleep were not recorded; and, -Resident #53's treatment administration record (TAR) was accurately documented. Findings include: I. Resident #85 A. Resident status Resident #85, under age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included cerebral palsy, legal blindness, reduced mobility, major depressive disorder, personality disorder, complete paraplegia and history of diseases of the musculoskeletal system and connective tissue. The 10/4/23 minimum data set (MDS) assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to prevent resident to resident altercations involving three (#1, #2 and #3) of three residents reviewed out of eight sample residents. Specifically, the facility failed to protect Residents #1 and #3 from physical abuse by Resident #2. Cross-reference F610, failure to investigate abuse incidents. Findings include: I. Facility policy and procedure The Resident to Resident Altercation policy, revised September 2022, was received from the nursing home administrator (NHA) on 9/6/23 10:10 a.m. The policy documented in part, All altercations, including those that may represent resident-to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. II. Resident status and record review A. Resident #1 (victim) Resident #1, age [AGE], was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, history…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to investigate an allegation of abuse for one (#1) of three residents reviewed for abuse out of eight sample residents. Specifically, the facility failed to thoroughly investigate an allegation of resident to resident altercation on 4/21/23 and an altercation on 8/29/23 between Resident #1 and Resident #2 in a timely manner. Cross-reference F600 resident to resident altercation. Findings include: I. Facility policy The Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating, dated 9/22/22, was provided by the nursing home administrator on 9/6/23 at 10:10 a.m. It read in pertinent part: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“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

$39,368 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $39,368 — penalty dated 2023-11-02
  • Medicare payment denial — starting 2023-12-02 for 47 days

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

Part of a chain

This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.9+0.1 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 1 of 52.5-1.5 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
PANTHER MASTER TENANT, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2023
PROVIDENCE GROUP NH, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 09/01/2023
REDDY, VIKASIndividualCONTRACTED MANAGING EMPLOYEEsince 07/21/2023
COLLAZO, ELIZABETHIndividualW-2 MANAGING EMPLOYEEsince 01/29/2024
APT, FREDERICKIndividualCORPORATE OFFICERsince 01/01/2024
HANCOCK, MARKIndividualCORPORATE OFFICERsince 01/01/2024
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 01/01/2024
MITCHELL, JOHNIndividualCORPORATE OFFICERsince 01/01/2024

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.

$6.1M
Net patient revenuemost recent cost report
-49.7%
Operating marginrevenue minus expenses
$151K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 3%Other / private 25%

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $151K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$414per resident / day
operating cost
$12,586per month
≈ monthly operating cost
$277per day
avg. revenue, all payers

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

What families pay in CO

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Colorado Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 065232. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-22, 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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