Rocky Mountain Care - Willow Springs

Location & what’s nearby

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

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

64.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 291 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 60.1% 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 143 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 112 beds and averages 107.8 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.20 hrs/resident/day on weekends vs 3.81 on weekdays — 16% thinner on weekends. RN hours go from 0.77 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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

Inspection deficiencies

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

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

32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.

• Actual harm · Gcited before2025-06-17 · 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 interview and record review, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 38 sampled residents, a resident who was identified as a two-person assist for bed mobility and incontinence care sustained a fall during a one-person assist for incontinence care. Resident identifier 264. Corrective Action: On 4/8/25, resident was assessed for injury; it was determined resident needed immediate medical attention and was sent to hospital via emergency medical services (EMS). Ensure two people were in the room when moving the resident, this included rolling and Hoyer transfers. Certified Nursing Assistant (CNA) 2 was put on leave until the investigation was completed. CNA 2 was moved to a different unit. On 4/14/25, CNA 2 completed the CNA Annual Checklist and education regarding APM settings and APM two person assist. On…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2024-08-01 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility did not ensure that 7 of 14 sampled residents were free of significant medication errors. Specifically, one resident received another resident's medications, which resulted in a hospital admission and subsequent continuous heart monitoring. Additionally, three residents did not receive medications according to physicians' orders, one received a medication for which the resident had a known allergic reaction, and two received the incorrect medications; these errors did not result in adverse outcomes. Resident Identifiers: 3, 7, 10, 11,12,13,14. Findings include: 1. Resident 3 was an [AGE] year old female who was admitted to the facility in 7/2020 with diagnoses which included benign neoplasm of the brain. On 7/30/2024 at 11:45 AM, a review of Resident 3's medical record was conducted. An incident report, dated 2/7/2024, was reviewed and indicated that Resident 3 had received her roommate's medications during the morning medication…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-10-18 · 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 observation, interview and record review it was determined for 1 of 51 sample residents a facility staff member did not ensure a safe environment while providing care. Specifically, resident 27 rolled out of bed when a Certified Nurse Aide (CNA) was changing the resident's bedding. Resident 27 sustained a bloody nose and a hematoma to her forehead. Findings include: Resident 27 was admitted to the facility on [DATE] with diagnoses that included; congestive heart failure, hypertension, type 2 diabetes mellitus, hyperlipidemia, anxiety disorder, depression, and morbid obesity. On 10/12/21, an interview was conducted with resident 27. Resident 27 stated she had experienced a fall when a CNA was changing her bedding following an incontinence brief change. Resident 27 stated the CNA did not have anyone assist her as she was changing the bedding. Resident 27 stated the CNA had her rolled over when the resident rolled off the bed, injuring the tops of both of her feet, her chest, shoulders and face. 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
• Actual harm · Gcited before2021-10-18 · 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 interview and record review, the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, 2 of 51 sample residents were not provided their physician-prescribed pain medications in a timely manner. This resulted in a finding of harm for resident 411. Resident identifiers: 97 and 411. Findings include: HARM 1. Resident 411 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, low back pain, repeated falls, hypertension, diabetes mellitus with neuropathy, and major depressive disorder. On 10/12/21 at 1:35 PM, an interview was attempted with resident 411. Resident 411 stated that she was in pain, and was waiting for staff to bring her pain medications. Resident 411 stated she did not want to speak to the surveyor at that time due to her pain. Resident 411 was observed to be moaning…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2021-10-18 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary 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 interview and record review, it was determined the facility did not ensure that each drug regimen was free from unnecessary drugs for 1 of 51 sample residents. An unnecessary drug is any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, the facility was not monitoring an anticoagulant medication. This resulted in a finding of harm for the resident. Resident identifier: 74. Findings include: Resident 74 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, edema, hypertension, diabetes mellitus, morbid obesity, anemia, venous insufficiency, and major depressive disorder. Resident 74's medical record was reviewed on 10/13/21. Resident 74's hospital discharge orders revealed that resident 74 was being administered 3 milligrams (mg) of warfarin daily, and that the resident's…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-31 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 interview and record review, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 10 sampled residents, notification to the SSA and APS was not done within 2 hours, when facility nursing staff observed a resident's brother kissing the resident on two different occasions Resident identifier: 3.Resident 3 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and acute systolic congestive heart failure. Resident 3's medical record was reviewed on 3/31/26. A review of the facility reported incident revealed that on two different instances resident 3 was observed by facility nursing staff to be kissing her brother on 12/28/25 and 1/4/26. Staff did not report the allegation of abuse to the facility administrator until 1/6/26. A review of the facility reported…

  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 · D2026-03-31 · 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 interview and record review, it was determined that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 10 sampled residents, a resident experienced a change in condition after a fall and was not sent to the hospital timely. Resident identifier: 4. Resident 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, generalized muscle weakness, other abnormalities of gait and mobility, and unspecified atrial fibrillation. Resident 4's medical record was reviewed on 3/31/26. A review of resident 4's progress notes revealed: a. On 12/21/25 at 10:22 PM, an order-administration note documented, .PT [patient] did have a fall around 1940 [7:40 PM] she doesn't remember what happened. b. On 12/21/25 at 11:56 PM, a nurses note documented, I was passing medications near the residents room at 1950 [7:50 PM] and I heard residents roommate hollering out about…

  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 before2026-03-31 · 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 interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 10 sampled residents, a resident with cognitive impairment eloped from the facility. Resident identifier: 2.Resident 2 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, ataxia, Wernicke's encephalopathy, alcohol dependence, opioid dependence, and traumatic subdural hemorrhage. Resident 2's medical record was reviewed on 3/31/26. A review of resident 2's elopement risk screening dated 12/5/25 revealed a score of 12 which indicated that resident 2 was at risk for elopement. A review of resident 2's progress notes revealed: a. On 12/5/25 at 10:58 PM, a nurse's note documented, Resident admitted to facility from [local hospital]. Resident is a 43 yr [year] old male with history of acute ischemic stroke and Wernicke's encephalopathy. Resident with a history of chronic methadone use and alcohol abuse with history 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 · D2025-06-17 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  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 interview and record review, the facility did not determine that the resident's right to self-administer medication was clinically appropriate. Specifically, for 1 out of 38 sampled residents, a resident was observed to have in their possession four inhalers for self-administration of the medications. Resident identifier: 58. Findings included: Resident 58 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (a-fib), chronic obstructive pulmonary disease (COPD), and emphysema. On 6/9/25 at 2:41 PM, an interview was conducted with resident 58. Resident 58 stated that their medication Arnuity caused her heart to have a-fib and they would rather have the medication Fluticasone. Resident 58 stated that she refused the Arnuity inhaler due to side effects of heart palpitations. Resident 58 stated that the facility gave her the medication and she self administered the inhalers. Resident 58 stated that she kept the Albuterol inhaler at bedside for emergency purposes. 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-17 · tag F0637 — isolated
  Assess the resident when there is a significant change in condition
  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 interview and record review, the facility did not comprehensively assess a resident within 14 days after determining, or should have determined, that there had been a significant change in the resident's physical or mental condition. Specifically, for 1 out of 38 sampled residents, a resident that was admitted to hospice services did not have a significant change Minimum Data Set (MDS) assessment completed. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cervical disc degeneration. On 6/9/25 at 3:34 PM, an interview was conducted with resident 1. Resident 1 stated that she had been on hospice maybe for a couple weeks. Resident 1 stated that hospice had made some changes with her medications. Resident 1's medical record was reviewed. A physician's order dated 5/8/25, documented to admit resident 1 to hospice. On 5/8/25, hospice admission paperwork was completed. On 5/9/25 at 8:00 AM, a Senior Health…

  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 · D2025-06-17 · 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 observation, interview, and record review, the facility did not ensure that services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality. Specifically, for 1 out of 38 sampled residents, medications were left unattended at a resident's bedside, consumption of those medications was not supervised by the licensed nurse administering them, and administration was not verified and completed in a timely manner. Resident identifier: 49. Findings included: Resident 49 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included heart failure, end stage renal disease (ESRD), dependence on renal dialysis, chronic respiratory failure, adrenocortical insufficiency, hypotension, anemia, type II diabetes mellitus, hypertension, hyperlipidemia, mood disorder, anxiety disorder, restless legs syndrome, dysphagia, insomnia, and pain. On 6/10/25 at 8:59 AM, an interview was conducted with resident 49. A pill cup filled with…

  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 · D2025-06-17 · tag F0775 — isolated
  Keep complete, dated laboratory records in the resident's record.
  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 interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 1 out of 38 sampled residents, the resident did not have laboratory results filed in their medical record. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included bilateral primary osteoarthritis of knee, type 1 diabetes mellitus with diabetic polyneuropathy, anxiety disorder, mood disorder due to known physiological condition with depressive features. Review of resident 18's medical record was completed on 6/9/25 through 6/17/25. On 4/25/25 at 10:44 AM, a Nurses Note revealed per physician's assistant orders: vaginal culture for yeast, trichomonas (trich) vaginalis, and sexually transmitted disease (STD). Diagnoses: vaginal discharge. On 4/25/25, a completed Physician's Order for yeast, trich, and STD one…

  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 · D2025-06-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  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, interview, and record review, the facility did not maintain records on each resident that were complete and accurately documented. Specifically, for 1 out of 38 sampled residents, a resident that received a narcotic did not have the narcotic signed out as administered. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cervical disc degeneration, bilateral primary osteoarthritis of knee, and chronic pain syndrome. On 6/9/25 at 3:34 PM, an interview was conducted with resident 1. Resident 1 stated that she was in pain and needed something. Resident 1 was observed to close her eyes and grimace. Resident 1 activated her call light and told Certified Nursing Assistant (CNA) 1 that she needed something for pain. CNA 1 stated that she would tell the nurse. Resident 1 stated that she had oxycodone four times a day and she could have another pain medication every hour. Resident 1 stated that her whole…

  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 · D2024-08-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 interview and record review it was determined, for 1 of 14 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, an allegation of neglect was not thoroughly investigated to determine if neglect had occurred. Resident identifier: 6. Findings include: Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of polyneuropathy, chronic respiratory failure, dementia, restless leg syndrome and type 2 diabetes mellitus. Resident 6's medical records were reviewed on 7/29/24 On 7/20/24 at 6:54 AM, a nurse note stated, Resident had fall and sent to Hospital. Aide said she went to change resident in her bed, then went to get a brief, then came back and resident was on floor. Resident said she saw her dog (stuffed animal) on the floor then all the sudden was on the floor. Nurse saw Resident facedown on the floor lying…

  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 · Dcited before2024-08-01 · 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 interview and record review it was determined, for 1 of 14 sampled residents, that the facility did not ensure that the residents received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was manually lifted by two staff members, instead of using a Hoyer lift, which resulted in an assisted fall to the ground. Resident identifier: 4. Findings Include: 1. Resident 4 was initially admitted to the facility on [DATE] and again on 1/6/24 with diagnoses which included contracture of right hand, sarcoid myocarditis, severe protein-calorie malnutrition, patellofemoral disorders of left knee, neuromuscular dysfunction of bladder, depression, generalized anxiety disorder, unspecified convulsions, foot drop of right foot, muscle weakness, age-related osteoporosis, and repeated falls. Resident 4's Electronic Medical Records were reviewed. On 4/24/24 a Quarterly Review of the Minimum Data Set (MDS) documented that resident 4 scored a 15 on the BIMS (Brief Interview for Mental…

  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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$40,892 in federal fines across 2 penalties.

• $9,269 — penalty dated 2025-06-17
• $31,623 — penalty dated 2024-08-01

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 ROCKY MOUNTAIN CARE — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 32 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). 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 UT