Clear Creek Care Center
7481 Knox Pl, Westminster, CO 80030 · For profit - Limited Liability company · 80 certified beds · (303) 427-7101 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2024
- it has 2 actual-harm citations
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 improved from 2 to 3 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 | 9.0% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.2% | 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 | 1.5% | 1.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.1% | 8.8% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 7.9% | 13.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.1% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.5% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.2% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.0% | 20.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.0% | 75.6% | 79.4% | better |
§ 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.
54.0% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 54.0%CMS range 41.0–67.6 | 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 | 10.0%CMS range 5.8–14.0 | 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 | 92.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 0.0% | 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 | 7.0%CMS range 4.1–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 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 80 beds and averages 73.0 residents a day — about 91% occupied, or roughly 7 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 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.81 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 3.09 hrs/resident/day on weekends vs 3.56 on weekdays — 13% thinner on weekends. RN hours go from 0.89 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2025-10-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#10) of four residents reviewed for accidents out of seven sample residents.Resident #10 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #10 was determined to be a high fall risk. On 8/30/25 Resident #10 sustained an unwitnessed fall. The facility updated the resident's care plan to indicate he needed a one-to-one caregiver. However, on 9/3/25 Resident #10 sustained an unwitnessed fall when he was found on the floor in his room with a laceration to his head. Resident #10 was transported to the hospital for further evaluation. Resident #10 sustained a three to four millimeter left tentorial subdural hematoma (brain bleed) and posterior left tenth and eleventh rib fractures. The facility failed to ensure the person-centered interventions were consistently in place. After the fall on 9/325, it was…
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.
- Actual harm · G2021-08-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, staff interviews and record review, the facility failed to ensure a dignified existence was provided for one (#40) of three residents reviewed out of 37 sample residents. Specifically, the facility failed to respond in a timely manner to Resident #40's requests for assistance after incontinence episodes and did not honor her request for a specific agency staff member to not work with her. Due to the agency staff member not providing timely incontinence care on one occasion in June 2021, the resident reported she felt embarrassed, that her health was being jeopardized and that her blood pressure increased. After the resident requested that agency staff member not work with her again, the agency staff member did work with the resident in July 2021. The resident requested to be changed by the agency staff member in July 2021 due to her skin becoming irritated. The agency staff member left the resident's room without providing care which made the resident feel like a second class citizen. Findings…
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 · D2025-01-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#2 and #1) of three residents reviewed for bathing out of three sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #1, who were dependent on staff for bathing, received their scheduled showers. Findings include: I. Facility policy and procedure The Bathing/Shower policy, revised February 2018, was provided by the regional clinical resource (RCR) on 1/21/25 at 4:24 p.m. It read in pertinent part, The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The documentation includes the date and time the shower/bath was performed, the name and title of the individual who assisted the resident with the shower, all the assessment data obtained during the shower,…
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 · F2024-03-21 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure facility menus met the needs of residents and were followed. Specifically, the facility failed to: -Ensure menu extensions were followed; and, -Ensure residents were provided with all menu options and substitutions were offered when appropriate. Findings include: I. Facility policy and procedure The Menus and Nutrition Adequacy policy and procedure, revised January 2024, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: Menus must meet the nutritional needs of residents in accordance with established national guidelines, be prepared in advance, be followed, be updated periodically and be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. The US Foods Detailed Menu Cycle Nutritional Analysis was provided by the facility on 3/21/24 at 9:03 a.m. It read in pertinent part: The facility offered a total of 2,000 Kcal (calorie) daily nutritional intake across all meals. Milk was to be offered at every meal, offering 118…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-03-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen; and, -Ensure the two facility ice machines were properly cleaned and sanitized according to the manufacturer's instructions. Findings include: I. Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen A. Facility policy and procedure The Cleaning and Disinfection of Environmental Surfaces policy, revised August 2019, was provided by quality mentor (QM) #1 on 3/20/24 at 5:43 p.m. It documented in pertinent part: Environmental surfaces will be disinfected (or cleaned) on a regular basis daily and when surfaces are visibly soiled. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Horizontal surfaces will be wet dusted regularly using clean cloths moistened with an EPA-registered hospital disinfectant (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 · E2024-03-21 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure residents were kept free from unnecessary medications for four (#15, #16, #33 and #76) of five residents reviewed for unnecessary medications out of 47 sample residents. Specifically, the facility failed to ensure informed consents were signed prior to the administration of psychotropic medications for Residents #15, #16, #33 and #76. Findings include: I. Facility policy and procedures The Psychopharmacological Policy, dated 3/10/23, was provided by quality mentor (QM) #1 on 3/20/24 at 12:42 pm. The policy revealed the community (facility) supported the appropriate use of psychopharmacological drugs that were therapeutic for residents suffering from mental illness. If a resident was admitted with orders for psychopharmacological drug use, the following would occur: a licensed nurse would review admission medication orders and ensure appropriate diagnosis for use of each medication from the primary care physician, the licensed nurse would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-21 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards on two of four medication carts. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; -Expired and discontinued medications were removed from the medication cart; and, -Labeled medications were legible. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised [DATE], was provided by quality mentor (QM) #1 on [DATE] at 12:42 p.m. The policy read in pertinent part: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Professional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-21 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review 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 disease and infection on two of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control practices; -Ensure high touch areas were cleaned; -Ensure staff followed proper hand hygiene practices; -Ensure hand hygiene was offered to residents prior to meals; and, -Ensure Foley catheter bags were hung in a sanitary manner. Findings include: I. Failure to ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (2021)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 written notification of room changes and roommate changes for two (#72 and #14) of four residents reviewed for notifications out of 47 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #72 and Resident #14 and/or their representatives. Findings include: I. Facility policy and procedure The Room Change and Room Change Notices policy, dated 11/4/23, was provided by quality mentor (QM) #1 on 3/21/24 at approximately 2:00 p.m. The policy read in pertinent part To ensure that residents are afforded their right to prior notification of room or roommate changes and the right to appeal these changes. Residents will be notified in advance of room or roommate changes and of their right to appeal these changes. The SSD/RSD (social service director/ resident service director) or designee will meet with the resident to explain the purpose of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one (#29) of two residents reviewed for abuse out of 47 sample residents was kept free from abuse. Specifically, the facility failed to ensure Resident #29 was kept free from physical abuse by Resident #27. Findings include: I. Facility policy and procedure The Abuse policy, revised 5/3/23, was provided by the nursing home administrator (NHA) on 3/17/24 at 5:13 p.m. It read in pertinent part: -Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#17 and #19) of two residents reviewed for ADLs out of 47 sample residents. Specifically, the facility failed to ensure Resident #17 and #19 received showers as scheduled. Findings include: I. Facility policy and procedure The Bathing policy was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: The facility will try to bathe residents in their preferred way at their preferred times. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease, hemiplegia (one sided paralysis), diabetes and neuromuscular dysfunction of the bladder. The 2/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure residents with limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM for one (#36) of one resident reviewed for limited ROM out of 47 sample residents. Specifically, the facility failed to ensure Resident #36 was provided with restorative services to maintain or prevent worsening of her right hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff). Findings include: I. Facility policy and procedures The Restorative Nursing Services policy, revised March 2018, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Residents may be started on a restorative…
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 16 citations
- Potential for harm · D2024-03-21 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#54) of one resident out of 47 sample residents. Specifically, the facility failed to ensure trauma assessments were conducted to determine the residents history of post-traumatic stress disorder (PTSD) and/or trauma, identify triggers and develop person centered interventions within the comprehensive care plan for Resident #54. Findings include: I. Facility policy The Trauma Informed Care policy and procedure, revised August 2022, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, Resident Assessment: Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents received food prepared in a form designed to meet their needs for two (#15 and #39) of four residents reviewed for therapeutic diets out of 47 sample residents. Specifically, the facility failed to provide meals prepared according to the prescribed food orders for Resident #15 and Resident #39. Findings include: I. Facility policy and procedure The Menus and Nutrition Adequacy policy, revised January 2024, was received from quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: Menus must meet the nutritional needs of residents in accordance with established national guidelines, be prepared in advance be followed, reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups, be updated periodically and be reviewed by the facility's dietitian or other clinically qualified nutrition…
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 · E2022-12-01 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure five out of five nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct annual nursing competencies. I. Facility policy and procedure The Competency of Nursing Staff policy, revised May 2019, was provided by the infection preventionist (IP) on 12/1/22 at 3:11 p.m. It documented in pertinent part, All nursing staff must meet the specific competency requirements of their respective licensure and certification. In addition, nurse assistants will participate in a facility-specific competencies-based staff development and training program, and demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents as identified through resident assessments and described in the plans of care. The facility assessment included an evaluation of the staff competencies that were necessary to provide the level and types of care specific to the resident population. Facility and resident-specific…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-01 · 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 and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of four medication carts and one of two storage rooms. Specifically the facility failed to: -Ensure loose medications in cart were properly disposed of; -Ensure temperature of refrigerators were kept within a safe range; and, -Ensure medications were labeled with open dates. Findings include: I. Manufacturer's recommendations According to the Tubersol package insert, retrieved 12/7/22 from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. II. Facility policy and procedure The Storage of medications policy, undated, received from the infection preventionist (IP) on 12/1/22 at 12:45 p.m. revealed in pertinent part, The facility stores all drugs and biologics in a safe, secure and orderly manner. Drugs and biologics used in the facility are stored under proper temperatures. Medications requiring refrigeration are stored in a refrigerator located in the drug room at nurses…
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 · E2022-12-01 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure an effective quality assurance improvement program (QAPI) to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to resident rights, quality of care, pharmacy services, and infection control. The facility failed to identify quality deficiencies and develop effective action plans to ensure systemic and lasting change and improvements in these areas. Specifically, the QAPI committee failed to identify and address concerns related to resident rights, quality of care, pharmacy services and infection control. Findings include: I. Cross-referenced citations Cross-reference F561: the facility failed to ensure one resident received showers according to their preference. Cross-reference F695: the facility failed to ensure physician orders documented the appropriate care and settings of a continuous positive airway pressure (CPAP) machine; failed to follow manufacturer's recommendations for cleaning the CPAP…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-01 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment in two of two units. Specifically the facility failed to: -Ensure proper hand hygiene during peri-care (providing care to private areas); -Ensure scissors were clean/sanitized before and and after wound care; -Ensure clean supplies were not stored in the soiled utility rooms; and, -Ensure high touch areas were cleaned in resident rooms. Findings include: I. Professional reference The disinfection of medical equipment, updated 5/24/19, retrieved on 12/8/22, from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, documented in part. Equipment; scissors, hemostats, clamps, blood pressure cuffs, stethoscopes should be disinfected with an EPA(Environmental Protection Agency)-registered disinfectant unless the item is visibly contaminated with blood; in that case a tuberculocidal agent (or a disinfectant with specific…
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 before2022-12-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for one (#32) of 17 residents reviewed for bathing preferences out of 22 sample residents. Specifically, the facility failed to provide consistent showers for Residents #32 according to their preferences and routine shower schedules. Findings include: I. Facility policy and procedures The Bathing policy, was developed on 11/25/15, was provided by the nursing home administrator (NHA) on 12/1/22 at 10:20 a.m. The policy revealed the facility would try to bathe residents in their preferred way and at their preferred times. For some residents, bathing could be a frightening and uncomfortable experience. This might be due to confusion, pride, pain or other reasons. Staff were to help minimize the discomfort by offering a choice. II. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the November…
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 before2022-12-01 · 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 (#26 and #52) residents out of three who required respiratory care received the care consistent with professional standards of practice out of 22 sample residents. Specifically, the facility failed to : -Ensure physicians orders documented the appropriate care of a continuous positive airway pressure (CPAP) machine for Resident #26; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #26's CPAP; -Accurately complete section O in Resident #26's comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of Resident #26's CPAP; and, -Clean and store Resident #52's nebulizer appropriately. Findings include: I. Facility policies and procedures The CPAP/BiPAP (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) Support, revised March 2015, was provided by the director 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 · Fcited before2021-08-12 · 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, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in two of two units. Specifically, the facility failed to: -Ensure staff wore masks appropriately while in areas of the facility with potential residents; -Ensure residents were offered hand hygiene before meals; and, -Ensure wound care was provided in a sanitary manner for Resident #54. Findings include: I. Ensure staff wore masks appropriately while in the areas of the facility with potential residents A. Professional reference The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, last updated 4/13/2020, retrieved 8/16/21 from:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-08-12 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review; the facility failed to honor resident choices for three (#9, #10, and #57) out of eight resident's reviewed for self-determination. Specifically, the facility failed to: -Ensure Residents #9, and #10 received showers according to their choice of frequency; -Ensure Resident #9 received a minimal standard of nail care according to the resident's choice; and -Honor Resident #57 choice to stay in bed. Findings include: I. Facility policy and procedure The policies and procedures for bathing and activities of daily living (ADLs) were requested on 8/11/21 at 12:35 p.m. However, the quality improvement specialist (QIS) said, The facility does not have those policies, we follow general standards of practice. II. Resident #9 A. Resident status Resident #9, age [AGE] , was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side 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 · Ecited before2021-08-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for five (#27, #40, #41, #42, and #55) of six residents reviewed for respiratory care out of 37 total sample residents. Specifically, the facility failed to: -Ensure oxygen tubing was marked with the date the tubing was replaced for Resident #27 and #41; -Obtain physician orders for oxygen that includes liter flow, frequency, and route for Resident #40 and #42; -Ensure oxygen was included on the comprehensive care plan for Resident #40; and, -Ensure CPAP machine was cleaned for Resident #27 and #55. Findings include: I. Facility policy and procedures The Oxygen Administration policy and procedure, revised October 2010, was provided by the director of nursing (DON) on 8/10/21 at 1:51 p.m. It read in pertinent part, Verify that there is a physician's order for this procedure. Review the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-12 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 provide services by sufficient numbers of personnel on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans on one of two halls reviewed for sufficient nursing staff. Specifically, the facility failed to provide sufficient certified nurse aide (CNA) staff to ensure Residents #10, #18, and #40, on Alpine Meadows, and Residents #14, #51, #54, #55 and #159 on Challenger Pointe had their call lights answered timely and showers were provided per resident preference and as scheduled for Residents #9, #10, #14, #54, and #159. Findings include: The facility assessment tool dated 6/2/21, provided by the nursing home administrator (NHA) on 8/8/21 at 3:11 p.m. indicated an average daily census of 50 residents. The staffing plan for certified nurse aides (CNAs) was four to nine daily (depending on census and acuity). I. Facility policy On 8/11/21 at 12:35 p.m. a policy was requested for staffing and the quality improvement specialist (QIS) said the facility did not have 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 · Ecited before2021-08-12 · 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, record review, and interviews the facility failed to ensure all drugs and biologicals were properly labeled, dated, stored/removed in one of two medication storage rooms and two of four medication carts. Specifically, the facility failed to ensure expired vaccines were removed timely and beverages were not kept in the same refrigerator for one of two medication storage room refrigerators as well as ensuring expired ear drops, throat spray, loose tablets, suppositories, and injectable medications were labeled and stored properly in two of four medication carts. Findings include: I. Facility policy The Medication Administration policy, dated 9/30/13, revised 11/26/19, provided by the quality improvement specialist (QIS) on 8/11/21 at 12:08 p.m., read in pertinent part: -The nurse is responsible to read and follow precautionary or instructions on the prescription labels. -Report any discrepancies to the pharmacy. -Note the physical appearance and packaging of the medication. Never administer medications from an unmarked container. -Follow the medication/pharmacy…
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 · D2021-08-12 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to prevent misappropriation of property for two (#6 and #15) of 12 residents reviewed for missing property, out of 37 sample residents. Specifically, the facility failed to: -Ensure Resident #6's new lock box was secured after her previous lock box with money went missing; and, -Prevent an agency staff member from taking rings from Resident #15. Findings include: I. Facility policy and procedure The Abuse policy, last revised 10/28/2020, was provided by the nursing home administrator (NHA) via email on 8/8/21 at 3:04 p.m. It read in pertinent part, (The facility) does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. -Misappropriation of resident property is defined as the deliberate misplacement,…
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 · D2021-08-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide care and services to prevent the development and worsening of pressure injuries for two (#15 and #54) of four residents reviewed out of 37 sample residents. Specifically, the facility failed to: -Notify the physician of a new toe wound, developed from a brace, to obtain treatment orders for Resident #54; and, -Prevent the development of a pressure wound to Residents #15's back when her air mattress deflated, and she was lying on her oxygen tubing. Findings include: I. Facility policy and procedure The Pressure Injury Prevention policy, revised 10/9/19, was received from the quality improvement specialist (QIS) on 8/12/21 at 10:40 a.m. The policy documented in pertinent part, a pressure injury is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). Although friction and shear are not primary causes of pressure injuries, friction and shear are important contributing factors to the development of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-08-12 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Ensure the storage of food in the nourishment/snack freezers was not stored with ice packs for residents in three out of four freezers; and, -Ensure all food items are labeled with date opened and resident name if a resident specific food item, and discard any opened, unlabeled, undated food items. Findings include: I. Facility policy and procedure The Food Receiving and Storage policy and procedure, revised December 2008, was provided by the registered dietitian (RD) on 8/11/21 at 11:33 a.m. It read in pertinent part, Food items and snacks kept on the nursing units must be maintained as indicated below: -All food items to be kept below 40 degrees F must be placed in the refrigerator located at the nurses ' station and labeled with a ' use by ' date. -All foods belonging to residents must be labeled with the resident's name, the item and the 'use by' date. -Refrigerators must have working…
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 $633K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 065120. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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