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Wheatridge Care Center

2920 Fenton St, Wheat Ridge, CO 80214 · For profit - Limited Liability company · 65 certified beds · (303) 238-0481 Medicare & Medicaid certified

Call the home — (303) 238-0481 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 2022Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$20,616 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2022
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $20,616 in federal fines (most recent 2025-06-12)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 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 — 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
6279 W 38th Ave · (720) 518-1164 · Call to confirm hours
Park
(303) 231-1300 · Typically dawn to dusk
Place of worship
3140 Fenton St

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 held steady at 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 weight7.4%4.7%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.6%0.9%better
Long-stay residents with a urinary tract infection1.5%1.4%2.0%better
Long-stay residents with depressive symptoms4.1%8.8%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.0%3.4%3.3%better
Long-stay residents whose ability to walk worsened5.4%13.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication1.1%11.5%18.9%better
Long-stay residents given the seasonal flu vaccine90.7%94.7%95.3%typical
Long-stay residents with pressure ulcers2.4%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control28.0%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table21.0%20.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.6%1.4%better
Short-stay residents given the seasonal flu vaccine59.0%75.6%79.4%worse

§ 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.

61.1% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.1%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
0.17U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

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

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

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 SNF61.1%CMS range 49.3–77.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.8–14.310.7%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 dischargenot 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 dischargenot 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 dischargenot 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 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 stay0.0%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 worsened4.8%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 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

0.63
RN hours/ resident / day
0.79
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.34
Total nurse hours/ resident / day
0.45
RN hoursweekends
50.0%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 54.0 residents a day — about 83% occupied, or roughly 11 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 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.12 hrs/resident/day on weekends vs 3.44 on weekdays — 9% thinner on weekends. RN hours go from 0.70 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

10
deficiencies at the latest standard inspection (2025-06-12)
6
at the previous standard inspection (2023-10-19)

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.

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2025-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured adequate supervision was provided for one (#18) of five residents reviewed out of 32 sample residents. Resident #18, who was at risk for falls related to weakness, multiple sclerosis (an autoimmune disease that affects the central nervous system) and a history of falls, was admitted to the facility on [DATE] for a long-term care stay due to the progressive nature of her illness. Per the resident's care plan, she required total staff assistance for activities of daily living (ADL), including showers. Resident #18 experienced an unwitnessed fall on 4/16/25 when she was left unsupervised in the main shower room, resulting in a fracture of her right femur. Specifically, the facility failed to provide adequate supervision for Resident #18 during her shower, which resulted in Resident #18 falling and sustaining a fracture of her right distal femur, which required…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2025-06-12 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to maintain an onsite and/or at least part-time infection control preventionist to properly assess, develop, implement, monitor, and manage the infection prevention and control program. Findings include: A. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was provided by the regional clinical resource (RCR) on 6/16/25 at 3:56 p.m. It read in pertinent part, The infection preventionist was responsible for coordinating the implementation and updating of the infection prevention and control program. Responsibilities included the following: The infection preventionist or designee coordinates the development and monitoring of the infection control program. The infection preventionist reports information related to compliance with 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-12 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#17, #51 and #7) of six residents were free from chemical restraints were receiving the least restrictive approach for their needs out of 32 sample residents. Specifically, the facility failed to: -Ensure Resident #17's behavior care plan had resident specific non-pharmacological care approaches; -Document consistent behaviors for Resident #17, Resident #51 and Resident #7 to justify the continued use of psychotropic medications; and, -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #51 and Resident #7's psychotropic medications. Findings include: I. Facility policy and procedure The Psychopharmacological policy, dated 3/10/23, was provided by the regional clinical resource (RCR) on 6/16/25 at 3:56 p.m. It read in pertinent part, The care plan will include the resident's focus and target behaviors for the medication. Realistic and measurable goals…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-12 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure services met professional standards of practice for four (#41, #111, #261 and #264) of 13 residents out of 32 sample residents. Specifically, the facility failed to ensure medications were not left at residents' bedsides and nurses monitored residents when they took their medications. Findings include: I. Professional reference According to [NAME] and [NAME], Clinical Procedures for Safer Patient Care (2015), retrieved on 6/17/25 from https://wtcs.pressbooks.pub/nursingskills/chapter/15-2-basic-concepts-of-administering-medications/#:~:text=The%20scope%20of%20practice%20regarding,in%20Open%20RN%20Nursing%20Pharmacology revealed, in pertinent part, Position the patient receiving oral medication in an upright position to decrease the risk of aspiration (choking). Patients should remain in this position for 30 minutes after medication administration, if possible. Remain with the patient until all medication has been swallowed before…

    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 · E2025-06-12 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 the facility had a designated registered nurse (RN) acting as the director of nursing (DON). Specifically, the facility failed to have a designated RN as the facility's fulltime DON. Findings include: I. Record review The facility's DON job description, created 12/28/22, was requested on 6/12/25 at 5:14 p.m. The job description was provided by the nursing home administrator (NHA) on 6/16/25 (after survey exit) at 4:59 p.m. It read in pertained part, Essential functions: Perform administrative duties such as: completing medical documents, reports, evaluations, studies, charting, evaluate accident/incident reports and implement interdisciplinary solutions, assure adequate supplies are available including but not limited to pharmaceuticals, resident personal supplies and equipment, prepare a plan of care for each resident that identifies the problems/needs, indicate the care to be given, goals to be accomplished and which professional service is responsible for each element of care, and coordinate with outside…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and in the dry storage area. Specifically, the facility failed to ensure: -The kitchen was clean and sanitary; -Food was labeled and stored correctly in the walk-in refrigerator, freezer and the dry storage area; and, -Staff wore hairnets in the main kitchen. Findings include: I. Failure to ensure the kitchen was clean and sanitary A. Professional reference The Colorado Retail Food Regulations (3/16/24), was retrieved on 6/16/25. It revealed in pertinent part, Physical facilities shall be cleaned as often as necessary to keep them clean. Plumbing fixtures such as handwashing sinks, toilets, and urinals shall be cleaned as often as necessary to keep them clean. Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#51 and #18) of three residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 32 sample residents. Specifically, the facility failed to: -Identify Resident #51 had a history of suicide attempts and suicidal ideation in order to monitor for worsening signs and symptoms of depression or suicidal ideation; and, -Address identified psychosocial distress impacting a resident's level of functioning for Resident #18, who expressed fear of showers after a fall with major injury in the shower. Findings include: I. Resident #51 A. Resident status Resident #51, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, Parkinson's disease and dementia. The 3/25/25 minimum data set (MDS) assessment documented the resident 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 that the medication error rate was not five percent (%) or greater. Specifically, the facility had a medication error rate of 24%, which was six errors out of 25 opportunities for error. Findings include: I. Facility policy and procedure The Medication Administration policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/11/25. It revealed in pertinent part, Observe that the resident swallows oral drugs. Do not leave medications with the resident. II. Medication error observations and interviews On 6/11/25 at 11:30 a.m. registered nurse (RN) #2 was preparing medications for Resident #41. RN #2 dispensed two medications, metoprolol and Lyrica, into a medication cup. She walked to Resident #41's room, handed the medication cup to the resident, told him those were his medications and walked away before the resident had a chance to take his medications. -RN #2 failed to ensure Resident #41 took his medications at the time they were administered. At 11:48 a.m. RN #2 was preparing…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in two of three medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure insulin pens were labeled with an open date; and, -Ensure inhalers were stored in a sanitary manner and labeled with resident names. Findings include: I. Facility policy and procedure The Medication Storage policy, undated, was provided by the regional clinical resource (RCR) on 6/11/25 at 4:30 p.m. It read in pertinent part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature. Only persons authorized to prepare and administer medications have access to locked medications. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to: -Ensure the housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high-frequency touched surfaces; and, -Ensure housekeeping staff performed appropriate hand hygiene. Findings include: I. Professional reference According to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection. (July 2021); Volume 113, Pages 104-114, retrieved on 6/21/25 from https://pubmed.ncbi.nlm.nih.gov/33744383/, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact…

    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 · Fcited before2023-10-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the kitchen, dish room and the dry storage room were identified and corrected in a timely manner. Findings include: I. Facility policies and procedures The Maintenance Service policy, revised December 2009, was provided by the director of clinical services (DCS) on 10/19/23 at 9:32 a.m. The policy revealed maintenance services should be provided to all areas of the building, grounds and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The maintenance personnel were to maintain the building in compliance with current federal, state and local laws, regulations and guidelines. The maintenance director was responsible for maintaining records/reports related to the inspection of the building, work order requests 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · F2023-10-19 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for one of one dumpsters. Specifically, the facility failed to contain garbage and refuse within the dumpster. Findings include: I. Facility policy and procedures The Food Related Garbage and Refuse Disposal policy, revised October 2017, was provided by the director of clinical services (DCS) on 10/17/23 at 1:36 p.m. The policy revealed garbage and refuse containing food wastes would be stored in a manner that was inaccessible to pests. Storage areas would be kept clean at all times and should not constitute a nuisance. Outside dumpsters provided by garbage pickup services would be kept closed and free of surrounding litter. II. Observations On 10/16/23 at 9:50 a.m. and 12:46 p.m. the facility dumpster was observed to have one of the two top lids open with eight bags filled with debris, overflowing out of the top of the dumpster. There were 14 bags filled with debris lying on the ground, against a metal building that was approximately eight feet away from the dumpster. On 10/17/23 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-19 · 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, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection in one out of three hallways. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Failure to clean glucometers in a sanitary manner; -Failure to wear gloves while obtaining a blood glucose and giving an injection; -Failure to maintain an intravenous (IV) antibiotic administration set in a sanitary manner; and, -Failure to maintain a catheter in a sanitary manner Findings include: I. Housekeeping A. Professional reference Centers for Disease Control (CDC). (5/4/23). Environment Cleaning Procedures. https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118 retrieved on 10/25/23. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Clean patient areas (patient…

    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 · Dcited before2023-10-19 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews the facility failed to provide services for two (#20 and #50) of three out of 29 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #20 and Resident #50's vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Professional reference Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine.https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 10/26/23. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. According to Kizior, R. J., [NAME], K. J. (2023). Metoprolol.…

    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 · D2023-10-19 · 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 one (#40) of five residents reviewed were provided with services or treatments to prevent the reduction in range of motion out of 29 sample residents. Specifically, the facility failed to ensure Resident #40 was provided with preventative measures for contracture of her right hand. Findings include: I. Facility policy The Resident Mobility and Range of Motion (ROM) policy, revised July 2017, was received by the nursing home administrator (NHA) on 10/17/23 at 4:54 p.m. It read in pertinent part: Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. As part of the resident's comprehensive assessment, the nurse will identify the resident's current range of motion of his or her joints, limitations in movement or mobility and opportunities for improvement. As part of the comprehensive assessment, the nurse will also…

    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 · D2023-10-19 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medications error for one (#14) of nine residents reviewed for medication error out of 29 sample residents. Specifically, the facility failed to ensure that Resident #14 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Professional reference According to the Lantus manufacturer guidelines, last updated 2022, retrieved from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf on 10/26/23 included the following recommendations, Perform a safety test. Dial a test dose of two units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure two residents (#6 amd #42) were free from resident-to-resident abuse out of 31 sample residents. Specifically, the facility failed to implement person-centered interventions to protect Resident #6, Resident #42 and Resident #13, who were roommates of Resident #35. Cross-reference F744: for failure to provide adequate dementia management care. Findings include: I. Facility policy The Abuse policy, updated 10/28/2020, was sent via email by the regional clinical resource (RCR) on 7/11/22 at 11:19 a.m. The policy read in pertinent part: Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse…

    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 · D2022-07-12 · 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 record review and staff interviews, the facility failed to ensure two (#4 and #30) residents reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 31 sample residents. Specifically, the facility failed to: -For Resident #4, accurately document skin assessments, investigate abrasions and trauma injuries, and ensure that dressings were applied to the wounds as ordered by a treating practitioner; and, -For Resident #30, administer medication in accordance with professional standards. Medications were left at the bedside, next to the resident. Findings include: I. Resident #4 A. Facility standards The Skin Tears-Abrasions and Minor Breaks was provided by the clinical nurse consultant on 7/12/22 at 9:46 a.m. In pertinent part, it read: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. When an abrasion/skin tear/bruise is discovered, complete a Report 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure one (#24) of two out of 31 sample residents who required respiratory care was provided such care and services consistent with professional standards of practice. Specifically the facility failed to ensure a physician's order was obtained for Resident #24's use of a CPAP (continuous positive airway pressure) machine to include the CPAP settings and cleaning procedures. Findings include: I. Facility policy and procedure The CPAP/BIPAP Support policy and procedure, revised March 2015, was provided by the regional clinical resource on 7/11/22 at 2:55 p.m. It read, in pertinent part, CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) can be used in conjunction with ventilation to improve oxygenation. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry…

    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 · D2022-07-12 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident who was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#35) of four out of 31 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care to prevent resident-to-resident altercations involving Resident #35. Cross-reference F600: for failure to ensure residents were free from verbal abuse. Findings include: I. Resident census and conditions The 7/11/22 resident census and conditions documented that 25 residents had a diagnosis of dementia and 15 residents had behavioral health care needs. The total census was 53 residents. II. Facility policy The Dementia Clinical-Protocol policy, revised November 2018, was sent via email by the regional clinical resource (RCR) on 7/11/22 at 11:19 a.m. The policy read in pertinent part: The staff and physician…

    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 before2022-07-12 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control. Specifically, the facility failed to have an individual with training in infection prevention and control (IPC) to provide onsite management of their COVID-19 prevention and response activities. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) (updated 2/2/22) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, retrieved on 7/13/22 read in pertinent part, A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Assign One or More Individuals with Training in Infection Control to Provide On-Site Management of the IPC Program. This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator 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.

    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

$20,616 in federal fines across 2 penalties.

  • $8,758 — penalty dated 2025-06-12
  • $11,858 — penalty dated 2023-12-26

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.

Part of a chain

This home belongs to VIVAGE SENIOR LIVING — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.5-0.5 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 5 of 55.0≈ chain avg
The other 5 homes this chain runs (chain average 3.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
MOSKOWITZ, JAYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 12/09/1998
BRAMMEIER, JOHNIndividualCORPORATE OFFICERsince 12/31/2011
QP HEALTH CARE SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/31/2011
QUALITY LIFE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/1999
KORETKE, MARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/20/2014

CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.8M
Net patient revenuemost recent cost report
-5.6%
Operating marginrevenue minus expenses
$606K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 3%Other / private 21%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $606K 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

$380per resident / day
operating cost
$11,547per month
≈ monthly operating cost
$360per 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 065308. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-12, 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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