Columbine Manor Care Center
530 W 16th St, Salida, CO 81201 · For profit - Corporation · 112 certified beds · (719) 539-6112 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (71%) runs well above the national median (45%)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.7% | 4.7% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 11.0% | 8.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.1% | 13.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 5.1% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 3.4% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 22.8% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.0% | 20.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 71.1% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.0% | 20.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.1% | 12.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.91 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.33 | 1.74 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.0% 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.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.0%CMS range 39.0–58.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.8–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | 96.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not 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 stay | 6.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.2–13.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 112 beds and averages 50.5 residents a day — about 45% occupied, or roughly 62 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.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.89 hrs/resident/day on weekends vs 3.39 on weekdays — 15% thinner on weekends. RN hours go from 1.14 to 0.80 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 71% 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
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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2026-04-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure residents were treated with respect and dignity was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life in one of one dining rooms. Specifically, the facility failed to ensure the residents did not have to wait in a long line to place their meal orders prior to entering the dining room and being seated for meals. Findings include:I. Facility policy and procedureThe Resident Dining Services policy, revised 4/29/25, was provided by the nursing home administrator (NHA) on 4/16/26 at 3:52 p.m. The policy read in pertinent part, The facility has an established process to ensure food is served in accordance with professional standards for food service and in a safe, clean, homelike environment. Dining services will include foods served timely and appropriate assistance provided to meet the individual needs of the residents to create a pleasant experience. A facility must treat each resident with respect and dignity and care for each resident in a manner and in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 one (#59) of three sample residents received notification of changes in eligibility for Medicare or Medicaid covered services, what the resident's financial responsibility may be, and their appeal rights.Specifically, the facility failed to ensure Resident #59 were provided with a Notice of Medicare Non-Coverage (NOMNC) when their skilled nursing benefits ended timely.Findings include:I. Facility policy and procedureThe Notice of Changes policy, revised on 4/1/26, was received from the nursing home administrator (NHA) on 4/16/26 at 3:52 p.m. It read in pertinent part, Residents will be told when charges will occur to their bills. The facility will fully inform the resident of services and related charges. The NOMNC form is given by the facility to all medicare beneficiaries at least two days before the end of a Medicare covered part A stay or when all of part B therapies are ending, The NOMNC informs beneficiaries of the right to expedite…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to store, prepare and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure potentially hazardous foods were monitored, held and cooled at appropriate temperatures; and, -Ensure dish room sanitation was maintained and dish room walls were a smooth cleanable surface. Findings include: I. Potentially hazardous foods monitored, held and cooled at appropriate temperatures A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 10/16/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, The person in charge shall ensure that: Employees are properly maintaining the temperatures of time and temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures; employees are using proper methods to rapidly cool time/temperature control for safety foods that are not held hot or are not for consumption within four hours, through daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases. Specifically, the facility failed to: -Ensure the facility had a way to test water for the growth of Legionella by using expired Legionella test kits; -Ensure staff properly disposed of personal protective equipment (PPE) when the facility had an outbreak of COVID-19; and, -Ensure staff properly maintained respiratory supplies by failing to change oxygen cannulas weekly for two residents when the facility had an outbreak of COVID-19. Cross-reference F882 infection preventionist qualifications Findings include: I. Facility policy The Infection Prevention and Control program and plan, dated [DATE], was received [DATE] by the infection preventionist (IP) and read in pertinent part, The facility has an ongoing infection prevention and control program to prevent, recognize, and control the onset…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-12 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to designate an interim infection preventionist (IP) that completed specialized training in infection prevention and control. Specifically, the full-time IP was on leave from the facility from 9/13/23 to 9/29/23 and 10/4/23 to 10/9/23. On 9/13/23 a resident tested positive for COVID-19, which led to a facility outbreak of COVID-19. From 9/13/23 to 10/2/23, twenty residents tested positive for COVID-19. The interim IP had not completed the education and training requirement prior to assuming the duties of the position. Findings include: I. Facility policy The Infection Prevention policy, dated 5/19/23, was received by the IP on 10/11/23 at 10:23 a.m. The policy documented in pertinent part, Our facility has an infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible. The facility has systems for the prevention, identification, reporting, investigation and control of infection and communicable diseases of residents, staff, and visitors. The system…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-12 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 record review and staff interviews, the facility failed to ensure four (#44, #103, #203 and #47) of seven out of 28 sample residents were provided services that meet professional standards of quality. Specifically, the facility failed to: -Clarify physician's orders and obtain dose information prior to administration of topical skin medication for Residents #44, #103 and #203; -Hold Digoxin (to treat heart failure) when Resident #47's heart rate was below 60; and, -Ensure consents and black box warnings were in place for the use of antidepressants before administration for Resident #47. Findings include: I. Topical skin medication orders A. Professional reference The Voltaren (Diclofenac) gel drug information was accessed on 10/11/23 on the Physicians Drug Reference website at https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. Diclofenac is a nonsteroidal anti-inflammatory (NSAID) medication that could be prescribed in intravenous, oral, topical, and ophthalmic formulations. The use of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#105) out of 10 residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to ensure Resident #105 was assessed by a registered nurse (RN) after a fall. Findings include: I. Resident status Resident #105, age above 65, was admitted on [DATE] and discharged [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included vascular dementia, weakness, unsteadiness on feet, difficulty in walking, non-traumatic acute subdural hemorrhage (brain bleed), lack of coordination and muscle weakness. The 4/14/23 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of one out of 15. He had physical and verbal behavioral symptoms directed towards others as well as other behavioral symptoms not directed at others, which put the resident at significant risk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 ensure two (#17 and #47) of 10 residents who required respiratory care received the care consistent with professional standards of practice out of 28 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place for the use of oxygen for Resident #17; and, -Ensure Resident #17 and Resident #47 received oxygen therapy as ordered. Findings include: I. Facility policy The Oxygen Administration policy, last revised 8/2/21, was provided by the nursing home administrator (NHA) on 10/11/23 at 2:31 p.m. It read in pertinent part: Oxygen will be administered in accordance with physician orders and current standards of practice. All facility staff will be educated on oxygen administration, safety, and storage upon hire, annually, and as indicated thereafter. Oxygen administration helps relieve hypoxemia (low oxygen levels)and maintains adequate oxygenation of tissues and vital organs. Verify the practitioner's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-10-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and the spread of foodborne illness, in one of one kitchens Specifically the facility failed: -To ensure the food was stored and labeled properly, and to discard leftover food after the use by date; -To ensure jewelry was not worn during food serving; -To ensure appropriate hand hygiene by food service staff; and, -To ensure the dishwasher maintained sufficient levels of sanitizing solution. Findings include: I. Labeling food A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) 3-701, 4 a-d. pg. 104, 4 a-d. It read in part, A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 12 of 22 resident rooms, three of three hallways. Specifically, the facility: -Failed to ensure walls, floors, and walls were repaired, painted and properly maintained and resident rooms were clean; and, -Failed to ensure oxygen concentrators were plugged into electrical outlets instead of a power strip. Findings include: I. Ensure walls, floors, and walls were repaired, painted and properly maintained and resident rooms were cleaned A. Initial observations Observations of the resident living environment conducted on 10/19/22 at 9:33 a.m. revealed: Room D-14: The floor underneath the resident's bed was dirty with trash and papers. The floor in the restroom had dried urine stains and dark stains around the base of the commode. Room D-11: The wall in the restroom had four pea size holes from the grab bar being removed and not replaced. The wall in the closet had a section approximately 12 inches and five inches wide, which had peeling 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.
Show the remaining 6 citations
- Potential for harm · E2022-10-20 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of two medication carts. Specifically, the facility: -Failed to discard an expired bottle of nitroglycerin tablets; -Failed to date a Novolog flex pen when opened; and, -Failed to date a Breo inhaler when opened. Findings include: I. Professional references According to the Breo Ellipta inhaler website, retrieved 10/19/22 from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Breo_Ellipta/pdf/BREO-ELLIPTA-PI-PIL-IFU.PDF, Safely throw away BREO ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads '0', whichever comes first. Write the date you open the tray on the label on the inhaler. According to the Novolog Flexpen website, retrieved 10/19/22 from: https://www.novo-pi.com/novolog.pdf, The NovoLog Flexpen you are using should be thrown away after 28 days, even if it still has insulin left in it. II. Observations and interview The medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-20 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to the facility and/or residents. Specifically, the facility failed to have a process for tracking and securely documenting the COVID-19 vaccination status of all staff and agency staff. Findings include: I. Facility policy and procedure The COVID-19 Vaccination Program for Associates policy and procedure, revised 9/6/22, was provided by the nursing home administrator (NHA) via email on 10/19/22 at 10:16 a.m. It read in pertinent part: The facility will ensure that individuals who provided any care, treatment or other services for the facility and/or its residents will be fully vaccinated against COVID-19, unless otherwise exempted by a medical or religious exemption. This included individuals under contract with the facility. The facility should track the following for elements related to associate vaccinations: -each staff member's vaccination status (this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#34) of two residents reviewed for activities out of 17 sample residents. Specifically, the facility failed to ensure Resident #34 was invited and encouraged to attend activities of her preference. Findings include: I. Facility policy and procedures The Therapeutic Activities Program policy and procedure, revised 11/2/21, was provided on 10/20/22 at 3:36 p.m., by the clinical consultant (CC). It read in pertinent part, The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#35) of five residents reviewed for quality of care out of 17 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 ted hose (stockings to help prevent blood clots) were placed on Resident #35 in the morning and taken off in the evening as prescribed by the provider. Findings include: I. Resident #35 A. Resident status Resident #35, age [AGE], was admitted on [DATE]. According to the October 2022 computerized physicians orders (CPO), diagnoses included dementia, depression, and localized edema. The 9/26/22 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. She had no identified behaviors. B. Record review The care plan, initiated 3/10/22, identified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#15) of three residents reviewed for the use of supplemental oxygen of 17 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #15. Findings include: I. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physicians orders (CPO), diagnoses included congestive heart failure, chronic respiratory failure, and chronic obstructive pulmonary disease. The 8/11/22 minimum data set (MDS) assessment revealed the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 interviews, the facility failed to ensure a proper pneumococcal immunization program for two (#30 and #39) of five residents reviewed for pneumococcal vaccine administration out of 17 sample residents. Specifically, the facility failed to offer and provide the pneumococcal vaccine to Resident #30 and Resident #39. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations (updated 1/22/22), retrieved from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html, accessed on 10/15/22, CDC recommends routine administration of pneumococcal conjugate vaccine (PPSV23) for all adults 65 years or older. In addition, CDC recommends PCV13 based on shared clinical decision-making for adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and have never received a dose of PCV13. Anyone who received any doses of PPSV23 before age [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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; 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 / manager | Type | Role | Since |
|---|---|---|---|
| PRESTON, FORREST | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/06/1976 |
| BOHNEN, DAWN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 04/28/2024 |
| MUHLBAUER, ANNELIESE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/23/2026 |
| SCHMIDT, DEREK | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 10/18/2012 |
| FLETCHER, TODD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2021 |
| LAY, LISA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 02/09/2018 |
| PRESTON, AUBREY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 03/06/2025 |
| SWANKER, RICHARD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2022 |
| ZIEGLER, JAMES | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 08/16/1999 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 04/21/1994 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/31/2006 |
| ARNETT, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2025 |
CMS files one row per role, so the 31 rows in the source record cover these 14 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.
1 organizational owner 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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. 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
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
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.
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 065220. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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.