Rock Canyon Respiratory And Rehabilitation Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

37.3% 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 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 80.7% 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 31 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 151 beds and averages 135.3 residents a day — about 90% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.80 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.58 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.47 hrs/resident/day on weekends vs 2.94 on weekdays — 16% thinner on weekends. RN hours go from 0.59 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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 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.

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.

41 citations, most serious first. The 17 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · Jcited before2022-12-15 · 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 record review, observations, and interviews, the facility failed to create an environment that protected two (#37 and #124) of six residents reviewed for abuse out of 38 sample residents. Resident #69, with moderate cognitive impairment, exhibited inappropriate sexual behavior toward one resident (#37) who had severe cognitive impairment. Resident #37 was sexually abused on 8/6/22 by Resident #69. In response to the 8/6/22 incident, the facility temporarily moved Resident #69 to another unit and provided one-on-one staff supervision for six days. Resident #69 returned to his original unit and 15 minute checks were instituted from 8/13/22 to 8/19/22. Supervision was changed to 30 minute checks between 8/20/22 and 8/31/22. The resident was returned to 15 minute checks on 8/31/22 however, this level of supervision was ineffective in protecting female residents on the unit from Resident #69's inappropriate sexual advances. Following the sexual abuse that occurred on 8/6/22, Resident #69 attempted to bring…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-03 · 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 record review and interviews, the facility failed to ensure one (#1) of one resident was free from mental anguish out of three sample residents. Resident #1 was admitted to the facility on [DATE] for long term care with a diagnosis of diagnoses included developmental disabilities, dementia, depression, anxiety, schizophrenia (mental illness), myocardial infarction (heart attack), nicotine dependence, hypertension (high blood pressure), coronary heart disease and chronic obstructive pulmonary (lung) disease (COPD). On 12/7/24, the facility staff noticed Resident #1 had a pipe used to smoke methamphetamines. The nursing home administrator (NHA) approached Resident #1 in order to find out where the resident was purchasing the drugs. The NHA asked Resident #1 if he could observe the resident purchase drugs to determine who was selling the drugs within the facility. Resident #1 told the NHA that he did not have any money. The NHA provided Resident #1 with $20 to purchase methamphetamines, so he could…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-07-12 · 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 the resident environment remained as free from accident hazards as possible for one (#20) of four residents reviewed for accident hazards out of 29 sample residents. Resident #20, who had severely impaired daily decision-making skills, was admitted on [DATE]. The facility determined the resident to be at risk for falls upon her admission and implemented a care plan with generalized fall risk interventions that were not individualized for Resident #20. Resident #20 sustained falls with minor injuries on 5/3/24, 5/10/24 and 5/16/24. Per interviews during the survey (from 7/12/24 to 7/16/24), the facility added fall interventions following each of the falls, however, the facility failed to update the interventions on the resident's care plan or ensure staff were consistently implementing the identified fall interventions for the resident. The facility additionally did not evaluate the fall interventions to determine 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-07-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#23 and #1) of nine residents reviewed for weight loss out of 29 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being Resident #23, admitted at nutritional risk and lost 14 pounds in six weeks. While nutritional interventions were initiated on admission (supplements three times a day) and again when a significant weight loss was identified on 6/20/24 (fortified foods), observations revealed the facility failed to promote the resident's nutritional status by encouraging, cueing and assisting the resident at mealtime, documenting his intake of snack and supplement, and addressing his agitation in the dining room at mealtime. No new interventions were considered when the resident continued to lose weight. Additionally, the facility failed to weigh Resident #1 upon admission to create a baseline to assess the resident's weight 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for for one (#1) of three residents reviewed for dental care out of five sample residents. The facility failed to provide emergency dental services for Resident #1. Resident #1's family was visiting on 4/16/23. The family notified the licensed nurse on duty of a broken, dark tooth, pain, discoloration and swelling to the resident's right lower jaw and neck.The family member said it was weeks before he was seen by a dentist, and the facility just kept giving him antibiotics. The resident received oral and intravenous (IV) antibiotics between 4/18/23 and 5/25/23 for repeat swelling and pain to the jaw. He was not seen by a dentist until 5/3/23, more than two weeks after he was observed with pain and swelling to his right jaw and neck. The dentist documented on 5/3/23, Resident #1 needed a root canal…

  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 · G2023-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening and infection of a pressure injury for two (#1 and #3) of four residents with pressure injuries out of five sample residents. Resident #1 admitted to the facility on [DATE] with intact skin. Resident #1 developed pressure injuries at the facility to his sacrum, left shoulder and right buttock. He had multiple comorbidities including a history of cardiogenic shock (heart not pumping enough blood to organs) and chronic respiratory failure, rhabdomyolysis (muscle tissue breakdown) and diabetes mellitus. He was at high risk for pressure injuries. The facility failed to initiate treatment when the sacral wound was first found on [DATE] for three days until [DATE]. The treatment administration records from [DATE] to [DATE] documented the wound care to his sacral, shoulder and right buttock wounds was held on multiple dates. The facility discussed the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-11 · 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 record review and interviews, the facility failed to ensure one (#5) of three residents reviewed out of five sample residents received respiratory care consistent with professional standards of practice. Resident #5 was admitted to the hospital from home on 6/28/23 with pneumonia. While at the hospital a tracheostomy was placed and the resident was placed on a mechanical ventilator (machine that breathes for you, ensures large enough breaths are taken). During the last week of the resident's hospitalization he was weaned from a ventilator down to a bi-level positive airway pressure (BIPAP, helps keep the airway open with positive pressure and gives more oxygen to the lungs, a person breathes on their own). The facility admitted the resident on 8/4/23. The facility placed him back on a mechanical ventilator. Facility records were requested that documented the resident was being weaned off the ventilator. The facility provided one respiratory note that was written during the survey and documented 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 before2025-12-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#7) of eight residents reviewed for abuse out of 13 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #7 from physical abuse by Resident #6. Findings include:I. Facility investigationThe facility investigation, dated 7/11/25, was provided by the DON on 10/14/25 at 12:44 p.m. The investigation revealed the following:On 7/11/25 Resident #6 was attempting to take food from a female resident (Resident #7). The female resident told Resident #6 to stop and Resident #6 hit the female resident. This incident occurred on the secured unit. The residents were separated and Resident #6 was given a new plate of food. Staff sat with Resident #6 until he was done with his meal and calmed down. Resident #7 was assessed and did not have any noted injuries. Neither resident was able to recall the incident.Interviews with facility staff members revealed Resident #6 approached Resident #7 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-05 · tag F0880 — failed to prevent and control infections — pattern
  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 on one of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident bathrooms; -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff performed appropriate hand hygiene; and, -Ensure individual glucometers were cleaned properly. Findings include: I. Housekeeping failures A. Professional reference According to 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. (July…

  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 · D2025-06-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  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 reasonable accommodation necessary to accommodate mobility and accessibility in the residents' environment for two (#119 and #120) of seven residents reviewed out of 43 sample residents. Specifically, the facility failed to ensure Resident #119 and Resident #120's call lights were within reach when the residents were in bed. Findings include: I. Facility policy and procedure The Call Light/Bell policy and procedure, revised January 2025, was received from the director of nursing (DON) on 6/5/25 at 3:15 p.m. It read in pertinent part, It is the policy of this facility to provide the resident with a means of communication with nursing staff and ensure the safety of residents. Leave the resident comfortable and safe. Place the call device within the resident's reach before leaving the room. II. Resident #119 A. Resident status Resident #119, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders…

  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 · D2025-06-05 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for one (#122) of five residents out of 43 sample residents. Specifically, the facility failed to ensure Resident #122, who was on antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements) did not worsen. Findings include: I. Professional reference According to the National Institute of Health (NIH) National Library of Medicine's Impact of A Pharmacist-Driven Tardive Dyskinesia Screening Process (7/16/21), retrieved on 6/10/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC8287863/#s1, According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), tardive dyskinesia (TD) is defined as involuntary movements generally of the tongue, lower face, jaw, torso, and extremities that are developed from the use of antipsychotics. These movements can either be choreiform (rapid and jerky) or athetoid (slow,…

  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 · Dcited before2025-06-05 · tag F0658 — failed to meet professional standards of care — isolated
  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 interviews, the facility failed to ensure one (#53) of five residents out of 43 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to ensure the physician's orders for Resident #53 contained the appropriate dose of the medication that was to be administered to the resident. Findings include: I. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 6/11/25 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Incorrect dosage is a prevalent modality of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if…

  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 · D2025-06-05 · 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 each resident with limited range of motion received appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in ROM for one (#33) of three residents reviewed for restorative services out of 43 sample residents. Specifically, the facility failed to ensure Resident #33's bilateral hand contracture soft splints were applied for contracture management per physician's order. Findings include: I. Facility policy and procedure The Restorative Care Program Overview policy and procedure, revised May 2018, was provided by the director of nursing (DON) on 6/5/25 at 2:30 p.m. It read in pertinent part, Provide direct nursing care services that will maintain optimum physical and mental health for the resident and meet his medical treatment needs. II. Resident #33 A. Resident status Resident #33, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2025 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 before2025-06-05 · 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 observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#15) of six residents reviewed for medication errors of 43 sample residents. Specifically, the facility failed to ensure that Resident #15 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration Findings include: I. Professional reference According to the Humalog Kwikpen manufacturer guidelines, last updated July 2023, retrieved on 6/12/25 from https://uspl.lilly.com/humalog/humalog.html#ug1 on 6/12/25 included the following recommendations, Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensuring that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up. Tap the cartridge holder gently 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 · F2024-07-12 · tag F0693 — failed to provide proper feeding-tube care — widespread
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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 with percutaneous endoscopic gastrostomy (PEG) tubes received treatment and services to prevent complications for eight (#10, #25, #13, #15, #12, #14, #16 and #11) of nine residents reviewed for tube feeding management out of 29 sample residents. Specifically, the facility failed to: -Label Resident #10, Resident #25, Resident #13, Resident #15, Resident #12, Resident #14, Resident #16 and Resident #11's tube feeding containers with the residents' names, room number, date, start time, formula type, feeding rate and nurse initials; -Provide Residents #10, Resident #12, Resident #14, Resident #15, Resident #16 and Resident #25, with the prescribed formula as written in the computerized physician orders (CPO); -Provide Residents #10, Resident #25 and Resident #13 with water flushes at the prescribed rate as written in the CPO; and, -Ensure the feeding pumps were calibrated for Residents #13, Resident #15, Resident #12,…

  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 · F2024-07-12 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) policy, revised 1/2022, was provided by the director of nursing (DON) on 7/12/24 at 6:23 p.m. The policy documented in pertinent part, The purpose of the QAPI plan and processes is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individuals' highest practicable physical, mental and social well-being. The committee will meet at least quarterly or more…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-07-12 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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 (ADL) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for six (#10, #16, #14, #6, #24 and #9) of 13 residents reviewed for ADLs out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #10, #16 and #14 received timely repositioning and toileting/incontinence care while in bed; -Ensure Resident #6 and #24 received timely repositioning and toileting/incontinence care; and, -Ensure Resident #9 received assistance with meals. Findings include: I. Professional reference According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 1214 read in pertinent part, Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin…

  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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$67,298 in federal fines across 2 penalties.

• $36,569 — penalty dated 2025-04-03
• $30,729 — penalty dated 2024-07-12

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

Part of a chain

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

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

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 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.

This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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