Villas At Sunny Acres, The

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.

52.9% 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 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 56.9% 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 58 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 160 beds and averages 143.2 residents a day — about 89% occupied, or roughly 17 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.68 hrs/resident/day on weekends vs 3.22 on weekdays — 17% thinner on weekends. RN hours go from 0.59 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below 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.

28 citations, most serious first. The 14 most serious are shown; the remaining 14 are one tap away and print in full.

• Actual harm · Gcited before2024-03-11 · 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's environment was free from accident hazards for three (#95, #12 and #19) of eight residents reviewed for falls out of 53 sample residents. Resident #95, who had a previous history of falls at the facility and was identified to be at high risk for falling, experienced a fall on 1/9/24 which resulted in a left hip fracture that required hospitalization and a left partial hip replacement. The facility failed to ensure effective and timely interventions were in place after 11/27/23 to prevent Resident #95 from sustaining a fall on 1/9/24 which resulted in a left hip fracture. The facility failed to ensure effective interventions to prevent additional falls on 2/6/24 and 3/1/24. The facility failed to timely assess and notify providers of the fall on 1/9/24 until two hours after Resident #95 began complaining of left lower extremity pain, when pain medication and a hip x-ray was ordered. The facility failed to notify 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 · G2024-03-11 · tag F0691 — failed to provide colostomy / ostomy care — isolated
  Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#130) of three residents reviewed for colostomy care out of 53 sample residents. Resident #130 was admitted to the facility on [DATE] with diagnoses of cognitive-communication deficit, anxiety disorder and with toxic megacolon (swelling and inflammation of the colon) that required a colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). Resident #130 required extensive assistance from staff for toileting and had a severe cognitive impairment according to the brief interview for mental status assessment. The facility failed to consistently assist Resident #130 with the care of the colostomy. The facility failed to ensure…

  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 · G2024-03-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#26) of three out of 53 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #26 displayed slurred speech, confusion, and left sided weakness resulting in an admission to the hospital on 1/17/24. It was concluded he had suffered from a stroke and was readmitted to the facility on [DATE]. On 1/21/24, the resident weighed 161.9 pounds (lbs). On 2/19/24, a month later, Resident #26 weighed 143.3 lbs. which was a 11.49% weight loss and a difference of 18.6 lbs. On his next weight on 3/7/24 (during the survey), the resident weighed 137.6 lbs. which was a 3.98% loss and a difference of an additional 5.7 lbs with a total of 18.6 lbs and 15.02% weight loss. According to the change of condition minimum data set (MDS) assessment dated [DATE], the resident required maximum assistance with eating. The MDS revealed the resident relied…

  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 · Gcited before2022-12-05 · 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 IV. Resident #119 A. Resident status Resident #119, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician's orders (CPO) diagnoses included legal blindness, cognitive communication deficit, muscle wasting and weakness, abnormalities of gait and mobility, and repeated falls. The minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition as evidenced by a brief interview for mental status with a (BIMS) score of five out of 15. The resident had severely impaired vision, adequate hearing, and did not reject care. The resident required extensive assistance from one staff member for toileting and personal hygiene. The resident needed limited assistance (guided maneuvering) with bed mobility and transfers. The resident used a manual wheelchair in the community and required supervision or assistance with moving from a sitting to standing position and transferring from surface to surface. The resident can walk 50 feet with supervision and staff…

  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 · D2026-04-08 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to prevent misappropriation of property for one (#7) of three residents reviewed for misappropriation of personal property out of 18 sample residents.Specifically, the facility failed to prevent the theft of Resident #7's narcotic medication card containing 89 pills.Findings include:I. Facility policy and procedureThe Abuse Prevention and Reporting policy, reviewed March 2026, was provided by the nursing home administrator (NHA) on 4/7/26 at 1:00 p.m. It revealed in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation. Exploitation-any occurrence involving misappropriation of a resident's property (deliberately misplacing, exploiting, or wrongfully using, either temporarily or permanently, a resident's belongings or money without the resident's consent).The Drug Diversion Reporting and Response policy and procedure, revised 3/16/24, was provided by the NHA on…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-03 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and texture. Findings include: I. Facility policy and procedure The Palatable Food policy and procedure, revised October 2021, was provided by the food and nutrition resource (FNR) on 4/4/25 at 1:45 p.m. It read in pertinent part, The facility will prepare and serve food that were palatable, attractive and at a safe and appetizing temperature. The facility will prepare food by methods that conserve nutritive value, flavor, and appearance. The facility will utilize pre-written menus. II. Observations On 4/3/25 at 11:31 a.m., the daily lunch menu was observed on the wall next to the entrance of the Longs Peak dining room. It revealed the menu was vegetable soup, house salad with dressing, orange-glazed chicken, Hawaiian rice, sugar snap peas, bread or roll with butter, chocolate cake and a choice of beverage. A test tray for a regular diet was evaluated by five surveyors immediately after 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-03 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 record review and interviews, the facility failed to inform the resident's representative of the change in condition for one (#176) out of five residents reviewed out of 49 sample residents. Specifically, the facility failed to timely notify Resident #176's representative of a fall, the need for medical imaging (Xray) of her left hip, new orders for pain medication and an appointment for a diagnostic imaging procedure to show detailed internal images (CT) scan in a timely manner. Findings include: I. Facility policy and procedure The Change of Condition Reporting policy, revised October 2020, was provided by the nursing home administrator (NHA) on 4/3/25 at 10:30 a.m. The policy read in pertinent part, The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. II. Resident #176 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide residents who were unable to carry out activities of daily living (ADL's) the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (#326 and #8) of five residents out of 49 sample residents. Specifically the facility failed to -Offer repositioning to Resident #326 and Resident #8, who were dependent residents; and, -Provide assistance with toileting for Resident #326. Findings include: I. Observations During a continuous observation on 4/1/25, beginning at 8:38 a.m. and ending at 12:39 p.m., the following was observed: At 8:39 a.m. Resident #326 was lying in bed with her eyes opened. She was leaning to the right side of her bed. Resident #8, who resided in the same room, was sleeping in her wheelchair. At 9:15 a.m. Resident #326 was lying in bed with her eyes closed leaning to the right side. Resident #8 was sitting in her wheelchair sleeping. The room smelled of urine. At 10:30 a.m.…

  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 · D2025-04-03 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 document resuscitation choices accurately in the medical record one (#376) of five residents reviewed for advance directives out of 49 sample residents. Specifically, the facility failed to ensure: -Resident #376 had a physician's order for their cardiopulmonary resuscitation (CPR) wishes in the resident's electronic medical record (EMR); and, -Resident #376's care plan included the resident's CPR wishes. Findings include: I. Facility policy and procedure The Advanced Directive policy, reviewed February 2025, was provided by the nursing home administrator (NHA) on [DATE] at 10:20 a.m. It read in pertinent part, Documentation shall be maintained in each resident's record. The facility will have a system for staff to identify the code status of each resident. II. Resident #376 A. Resident status Resident #376, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician's orders (CPO), diagnoses included esophageal obstruction,…

  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 before2025-04-03 · 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 provide adequate supervision to keep residents free from accidents/hazards for one (#276) of one resident out of 49 sample residents. Specifically, the facility failed to prevent an elopement from the secured unit building for Resident #276. Findings include: I. Facility policy and procedure The Elopement/Unsafe Wandering policy and procedure, revised June 2024, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, To provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion and can be either goal directed or nongoal directed/aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization and or any necessary supervision to do so. Residents with capabilities of ambulation and/or mobility 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-03 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#116) of two residents reviewed for dialysis out of 49 sample residents. Specifically, the facility failed to: -Consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center; and, -Ensure thorough documentation was completed for Resident #116 dialysis treatments. I. Facility policy and procedure The Renal Dialysis, Care of Resident, Hemodialysis Access Site policy and procedure, revised December 2020, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, It is the policy of the facility to provide standards in the care of the residents on renal dialysis and the care of the vascular access site for hemodialysis. The facility licensed nurse will complete the baseline information, pre- and post-dialysis section of the nurse…

  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 before2025-04-03 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 diagnosed with dementia received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#276) of one resident out of 49 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #276. Findings include: I. Facility policy and procedure The Specialized Dementia and Behavioral Care Program policy and procedure, undated, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, The Specialized Dementia and Behavioral Care Program includes a secured unit (SU) designed to meet the needs and ensure the safety of individuals with Alzheimer's, dementia/delirium, psychiatric/behavioral diagnoses, and other diagnoses deemed appropriate for the secured unit by the admissions assessment. To respond to the needs of both…

  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 · D2025-04-03 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, and interviews, the facility failed to ensure all drugs and biologics were properly stored and labeled for one (#101) of two residents reviewed out of 49 sample residents. Specifically, the facility failed to ensure medications that were not administered were not left unsecured at Resident #101's bedside. Findings include: I. Facility policy and procedure The Medication Access and Storage policy and procedure, revised August 2019, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. II. Resident #101 A. Observation and resident interview On 3/31/25 at 3:20 p.m., during an interview with Resident #101, a white rectangular box labeled lidocaine hydrochloride (hcl) 3% cream (topical pain medication) was on the resident's bedside table. Inside the box was a used tube labeled lidocaine hcl 3% cream. Resident #101 said the staff applied the cream…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-03 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of seven units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for Resident #326 and #95, who were both on enhanced barrier precautions (EBP) for pressure wounds. Findings include: I. Failed to ensure staff wore the appropriate PPE for Resident #326 and #95, who were both on EBP for pressure wounds A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 4/3/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, Enhanced barrier precautions (EBP) are an infection control…

  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

“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

$19,988 in federal fines across 1 penalty.

• $19,988 — penalty dated 2024-03-11

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 13 rows in the source record cover these 9 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.

3 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 $2.0M 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