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Rehabilitation Center At Sandalwood, The

3835 Harlan St, Wheat Ridge, CO 80033 · For profit - Limited Liability company · 103 certified beds · (303) 422-1533 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2023Resident-funds citation (F0567)1 immediate-jeopardy citation$46,150 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2023
  • it has a citation for mishandling residents’ money or property (F0567)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $46,150 in federal fines (most recent 2024-04-26)
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 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 quality-measure rating runs 2 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6279 W 38th Ave · (303) 907-1255 · Call to confirm hours
Pharmacy
3770 Sheridan Blvd · (720) 855-8477 · Call to confirm hours
Grocery
5301 W 38th Ave · (303) 425-7356 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
3550 Sheridan Blvd · (720) 505-8270

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.1%13.4%15.4%better
Long-stay residents who lose too much weight2.1%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.6%0.9%better
Long-stay residents with a urinary tract infection2.8%1.4%2.0%worse
Long-stay residents with depressive symptoms8.7%8.8%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.6%3.4%3.3%worse
Long-stay residents whose ability to walk worsened15.9%13.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication4.6%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine93.7%94.7%95.3%typical
Long-stay residents with pressure ulcers2.1%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control19.6%21.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table5.5%20.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.6%1.4%typical
Short-stay residents given the seasonal flu vaccine67.3%75.6%79.4%worse
Short-stay residents rehospitalized after admission15.1%20.3%22.6%better
Short-stay residents with an outpatient ER visit4.9%12.1%12.0%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.

49.1% 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 133 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
55.6%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 55.6% 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 27 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.1%CMS range 39.0–55.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.1–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge70.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.1–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.75
RN hours/ resident / day
0.69
LPN hours/ resident / day
2.14
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.42
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 103 beds and averages 82.7 residents a day — about 80% occupied, or roughly 20 beds typically open. It usually has some room. 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.23 hrs/resident/day on weekends vs 3.71 on weekdays — 13% thinner on weekends. RN hours go from 0.88 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

4
deficiencies at the latest standard inspection (2026-02-11)
9
at the previous standard inspection (2024-04-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · L2024-04-26 · tag F0756 — failed to review each resident's drug regimen — widespread
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY B. Resident #15 1. Resident Status Resident #15, age [AGE], was admitted on [DATE]. According to the April 2024 CPO, diagnoses included dementia with behavioral disturbances, bipolar disorder (mental illness causing shifts in mood, energy, activity levels, and concentration), personality disorder (thoughts, feelings, and behaviors different from an established societal norm), anxiety, arthritis, history of falls, contractures (permanent tightening of the muscles and tendons causing joints to shorten and stiffen) of right foot ankle and hand and chronic kidney disease. The 3/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance from one staff member for dressing, toileting, and setup with personal hygiene. Section E of the MDS indicated Resident #15 had not exhibited behavioral symptoms of hitting, kicking, pushing, grabbing, threatening others, screaming at others, or cursing at others. A review of the resident's care plan revealed…

    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
  • Actual harm · Gcited before2024-04-26 · 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 interviews and record review, the facility failed to provide timely and effective interventions to prevent weight loss for one (#41) of four residents reviewed for weight loss out of 35 sample residents. Resident #41 was admitted to the facility for long term care on 1/14/23 and readmitted on [DATE] with diagnoses of hyper-[NAME] syndrome (a rare immunodeficiency syndrome), anemia (low blood count) and dementia. Resident #41 had multiple food allergies, including soy protein, brussels sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. On 10/1/23, Resident #41 weighed 139 pounds (lbs). On 10/15/23, Resident #41 weighed 119.2 lbs, which indicated the resident had lost 19.8 lbs. The registered dietitian (RD) requested the resident to be reweighed on 10/16/23, 10/19/23, 10/24/23 and 10/26/23. The resident was not reweighed until 10/26/23, 10 days after the initial reweigh was requested, where she weighed 116.5 lbs. The resident had lost 16.2% (22.5 lbs) in 25 days, which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 possible development and transmission of infectious diseases on two out of three units.Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers cleaned high touch areas; -Ensure hand hygiene was completed during room cleaning; and,-Ensure dwell times were followed per manufacture recommendations. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised [DATE]) was retrieved on [DATE] from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    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 a resident choices regarding their personal funds for one #11) of two residents reviewed for personal funds out of 35 sample residents. Specifically, the facility failed to provide resident choices for storage of funds. Findings include:I. Facility policy and procedureThe Accounts Receivable policy, dated 1/1/26, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:41 p.m. The policy reads in pertinent part: The resident has the right to manage their financial affairs. Residents are not required to deposit their personal funds into the facility resident trust account.II. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included cancer, type two diabetes, heart failure and chronic kidney disease.The 11/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief…

    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 · D2026-02-11 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for one (#80) of five residents reviewed for quality of care out of 35 sample residents. Specifically, the facility failed to ensure Resident #80 was assessed by a registered nurse (RN) following a fall on 12/13/25. Findings include:I. Facility policy and procedureThe Fall Management System policy and procedure, revised 1/20/26, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:41 p.m. It read in pertinent part, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. When a resident sustains a fall, a physical…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-11 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure 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) to ensure the highest practicable quality of life and care, for two (#12 and #70) of three residents reviewed for ADLs out of 35 sample residents.Specifically, the facility failed to:-Ensure denture care was provided for Resident #12; and,-Ensure Resident #70 received meal assistance. Findings include: I. Facility policy and procedure The Activities of Daily Living policy, dated 7/1/24, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:41 p.m. The policy read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. II.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-26 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set 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 program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication regimen review (MRR) by not providing physicians with the pharmacist recommendations so the physicians could respond to the recommendations timely which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. Facility policy The Quality Management Plan/QAPI program (Quality Assurance and Performance Improvement) policy and procedure, revised 11/15/2018, was provided by the nursing home administrator (NHA) on 4/26/24 at 12:50 p.m. It read in pertinent part, Our quality assurance and performance improvement (QAPI) program objective is 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-26 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure 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, interviews and record review, the facility failed to ensure one (#63) of one resident reviewed for activities of daily living out of 35 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to: -Provide Resident #63, who had difficulty with communication, with an appropriate communication tool to ensure the resident was able to effectively communicate his needs to staff; and, -Create a person-centered care plan for Resident #63 which addressed his communication deficits. Findings include: I. Facility policy and procedure The Person-Directed Care Plans policy and procedure, reviewed 7/12/22, was provided by the nursing home administrator (NHA) on 4/25/24 at 1:50 p.m. It read in pertinent part, The purpose of long term person-directed care plans is to tell a resident story. Care plans will be developed consistent with the resident's specific conditions, risks, needs, behaviors, preferences, and current…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#17) of one resident out of 35 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents'choices. Specifically, the facility failed to ensure Resident #17 received a new CPAP (continuous positive airway pressure) mask timely. Finding include: I. Resident #17 A. Resident Status Resident #17, age [AGE], was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included obstructive sleep apnea (intermittent obstruction of the airway during sleep), chronic respiratory failure with hypoxia (decreased oxygen) and dependence on supplemental oxygen. The 3/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required extensive assistance of one staff member with dressing and personal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#15 and #10) of two residents reviewed for limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #15 was monitored for the use of splints (devices that stabilize a part of your body and hold it in place); and, -Ensure Resident #10 was properly positioned in her wheelchair to ensure her head was in a comfortable position. Findings include: I. Resident #15 A. Resident Status Resident #15, age [AGE], was admitted on [DATE]. According to the April 2024 CPO, diagnoses included hemiplegia (severe or complete loss of strength) and hemiparesis (weakness or the inability to move on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side, arthritis (painful inflammation and stiffness of the joints) and contracture (shortening and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-26 · 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 interviews and record review, the facility failed to provide an environment free from accident hazards and risks as possible for three (#60, #52 and #43) of seven residents reviewed for accidents/hazards out of 35 sample residents. Specifically, the facility failed to -Ensure neurological checks were completed per standards of practice after Resident #60 sustained unwitnessed falls; and, -Ensure staff were properly trained to assist Resident #52 and Resident #43 with slide board transfers after the residents sustained falls during transfers. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, revised on 2/1/24, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m. It read in pertinent part, A fall is defined as the failure to maintain an appropriate lying, sitting, or standing position, resulting in an individual's sudden, unintentional relocation either to the ground or into contact with another object below the starting point.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-26 · 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 one (#191) of two residents out of 35 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure consistent communication and documentation with the dialysis center occurred regarding care and services provided for Resident #191. Findings include: I. Facility policy and procedure The Dialysis Care Policy, reviewed 7/12/23, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m., It read in pertinent part, Coordination of dialysis care will include communication about code status, change in medications, current vital signs, weight management, required treatments, care concerns and appropriate interventions and fluid restriction management limitations. This information will be sent with the resident to their dialysis appointments. II. Resident #191 A. Resident status Resident #191, age [AGE], was admitted on [DATE]. According to the April 2024…

    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
Show the remaining 11 citations
  • Potential for harm · D2024-04-26 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#5) of one resident reviewed for ancillary services, such as dental services, out of 35 sample residents received routine and 24-hour emergency dental care. Specifically, the facility failed to provide Resident #5 with timely dental care when she sustained a broken tooth. Findings include: A. Resident status Resident #5, under age [AGE], was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included heart failure, arthrodesis (joint fusion to relieve arthritis pain) and chronic pain. The 3/12/24 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. She was independent with all activities of daily living (ADL). B. Resident interview Resident #5 was interviewed on 04/22/24 at 2:29 p.m. Resident #5 said a piece of her tooth fell out last month (March 2024) while she was brushing her teeth…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #2) of three residents reviewed for pressure injuries/ulcers out of five sample residents. Specifically, the facility failed to: -Ensure Resident #2's was provided and encourage proper repositioning to prevent the development of new pressure injuries; and; -Ensure Resident #1's pressure injury treatment was consistently changed per physician orders. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/1/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure four (#17, #18, #58 and #62) of six residents received adequate supervision to prevent accidents out of 33 sample residents. Specifically, the facility failed to: -Develop and implement a person-centered care plan that identified Resident #17 fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #17; -Ensure registered nurse (RN) assessments were completed following falls for Resident #18; -Ensure Resident #58 plan of care identified that the resident was a wander risk and had eloped from the facility on one occasion with person-centered interventions to prevent further elopement episodes, ensure a physician's order was in place with consent obtained for the use of the wanderguard system and monitored the placement and function of the wanderguard; and, -Ensure Resident #62 was being monitored during meals due to his high aspiration rate. Findings include: I. Resident #17 A. Resident status Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 interviews and record review the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for two (#13 and #133) of six residents reviewed out of 33 sample residents. Specifically, the facility failed to: -Respect the wishes of Resident #13 to receive showers and not bed baths; and -Provide showers according to Resident #133's plan of care/preference. Findings include: I. Facility policy The Dignity, Voice, and Choice policy and procedure, revised 8/10/22, was provided by the nursing home administrator (NHA) on 1/10/22 at 4:00 p.m. It revealed in pertinent part, Residents will be cared for in a manner and environment that maintains or enhances their dignity, privacy, and respect in full recognition of their individuality. Choices and decision making belong to our residents. Bathing services are provided per residents' preferences, time, day, caregiver, shower or bath preferences and are honored as much as reasonably…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for two (#36 and #58) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to prevent: -Resident #36 from physical abuse by Resident #83. Resident #83 had documented aggressive behaviors prior to the physical abuse incident on 8/22/22; and, -Resident #58 from physical abuse by Resident #17. Resident #17 had prior behaviors which the facility documented that she did not get along with prior roommates. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 1/12/23), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 develop and update a comprehensive care plan for three (#53, #58 and #7) out of 33 sample residents for services that were to be furnished to attain or maintain the practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #53's comprehensive care plan addressed the resident's use of antidepressant medication; -Ensure Resident #58's use of anticoagulant medication was addressed in the comprehensive care plan with person-centered interventions; and, -Ensure Resident #7's behaviors were identified in the comprehensive care plan with person-centered interventions in place. Finding include: I. Facility policy and procedure The Person Directed Care Plan policy and procedure, revised on 7/12/22, was provided by the nursing home administrator (NHA) on 1/12/23 at 11:47 a.m. It read, in pertinent part, Baseline care plans will be completed within 48 hours of admission by the required departments and a copy…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#67) of seven out of 33 sample residents. Specifically, the facility failed to ensure that Resident #67, who was high risk and had skin breakdown, was offered and repositioned in a timely manner. Findings include: I. Professional reference According to Pechlivanoglou, P. et al. Turning high risk patients: An economic evaluation of repositioning frequency in long term care. Journal of the American Geriatrics Society. 2018 July; 66(7): 1409-1414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6097929/ retrieved on 1/12/23. According to current US (United States) practice guidelines, nursing home residents should be repositioned as frequently as required by their condition. Practice guidelines in Canada and the US recommend that patients at high risk of pressure ulcers be repositioned every two hours. II. Resident #67 A. Resident status Resident #67,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#58) out of 33 sample residents. Specifically, the facility failed to ensure Resident #58 was monitored for use of an anticoagulant medication. Findings include: I. Resident status Resident #58, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included long term (current) use of anticoagulants. The 12/6/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. II. Observation On 1/5/23 at 1:10 p.m. Resident #58's top left forearm was observed to have a large brown oval shaped skin discoloration. III. Record review The January 2023 CPO documented…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · 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 effective interventions were in place to address weight loss timely in one (#42) of two sample residents out of 33 sample residents. Specifically, the facility, after identifying weight loss in a resident at high risk for nutritional and hydration deficits, failed to provide effective person centered interventions to assist in preventing additional weight loss and further deterioration of nutrition and hydration status. Findings include: I. Professional reference Roigk, P. (2018). Chapter 8: Nutrition and Hydration. In K. [NAME] and J. [NAME]-[NAME] Eds. Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient (Internet). [NAME] Publishing. https://www.ncbi.nlm.nih.gov/books/NBK543833/ retrieved on 1/17/23 at 4:58 p.m. According to the North American Nursing Diagnoses Association ([NAME]) malnutrition is: 'Intake of nutrients insufficient to meet metabolic needs'. The criteria for malnutrition are:…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to establish parameters for pain medication for two (#50 and #5) of two residents in a manner consistent with professional standards of practice out of 33 sample residents. Specifically, the facility failed to: -Pain parameters were implemented on pain medications ordered and the location of pain was identified on the physician order for Resident #50; and, -Pain parameters ordered for pain medications were followed for Resident #5. Findings include: I. Facility policy and procedure The Pain Management policy and procedure, reviewed 11/1/18, was provided by the nursing home administrator (NHA) on 1/12/23 at 11:47 a.m. It revealed in pertinent part, The pain interview will include: record review for scheduled, PRN, and non-medication pain interventions; residents will be evaluated to determine ability to answer questions based on minimum data set (MDS) 3.0 guidelines. If a resident is unable to respond to questions or cue cards, staff interviews will be…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · 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, 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 one out of three units. Specifically, the facility failed to: -Ensure contaminated gloves were removed and hand hygiene was performed after providing incontinence care and before touching the barrier cream tube; -Ensure soiled gloves from incontinence care were removed and hand hygiene performed before touching outside packaging of incontinence wipes; and, -Ensure soiled packaging of incontinence wipes and barrier cream were disposed of prior to placing it on the nightstand. Findings include: I. Professional reference Centers for Disease Control and Prevention (CDC). Hand Hygiene in Healthcare Settings: Hand Hygiene Guidance. Reviewed January 30, 2020. https://www.cdc.gov/handhygiene/providers/guideline.html retrieved on 1/12/23. Healthcare personnel should use an alcohol based hand rub or wash with soap and water for the following…

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$46,150 in federal fines across 1 penalty.

  • $46,150 — penalty dated 2024-04-26

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.

Who owns this facility

Owner / managerTypeRoleSince
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.

$11.1M
Net patient revenuemost recent cost report
-7.6%
Operating marginrevenue minus expenses
$1.2M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 9%Other / private 43%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$404per resident / day
operating cost
$12,271per month
≈ monthly operating cost
$375per day
avg. revenue, all payers

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

What families pay in CO

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 065292. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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