Rocky Mountain Care - Hunter Hollow

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.

60.3% 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 105 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 79.0% 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 38 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 124 beds and averages 109.9 residents a day — about 89% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.30 hrs/resident/day on weekends vs 3.87 on weekdays — 15% thinner on weekends. RN hours go from 1.16 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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 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.

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.

26 citations, most serious first. The 16 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2023-10-26 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a resident was sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access and abuse of the resident by the alleged perpetrator. This requirement was determine to be out of compliance at the severity level of immediate jeopardy. Due to the ongoing access to resident 1, by the alleged perpetrator, the scope of the noncompliance is determined to be a pattern. Resident identifier: 1. NOTICE On 10/25/23 at 3:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally and in writing to the facility…

  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
• Immediate jeopardy · K2023-10-26 · tag F0610 — failed to investigate and act on abuse reports — pattern
  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 observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a staff member had an allegation of sexual abuse toward resident 1 that was not thoroughly investigated in July 2022. An additional allegation of sexual abuse of resident 1 was made against the same staff member in September 2023 that substantiated abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access to the resident by the alleged perpetrator. This was found to have occurred at an immediate jeopardy (IJ) level. Resident identifier: 1. NOTICE On 10/25/23 at 3:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally and in writing to the facility…

  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
• Immediate jeopardy · J2023-10-26 · 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 confidential and non-confidential interviews with administrative staff, therapy staff, licensed and unlicensed nursing staff, and record review, it was determined, for 1 of 9 sampled residents, the facility failed to ensure that all suspected or alleged violations involving abuse were reported immediately to the administrator and other officials in accordance with State law through established procedures. Specifically, when interviewed by surveyors, multiple staff reported observing Certified Occupational Therapy Assistant (COTA) 1 interacting with resident 1 in a suspicious manner and did not report their concerns, thereby, allowing COTA 1 ongoing access to resident 1. The facility's noncompliance relative to identifing and reporting abuse was determined to be at the severity level of immediate jeopardy. Due to the repeated occurrence and number of staff who failed to report their concern, the scope was determined to be a pattern. Resident identifier: 1. NOTICE On 10/25/23 at 3:30 PM, an Immediate…

  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
• Actual harm · Gcited before2025-12-22 · 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 11 sampled residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident was not provided two person assistance during a brief change, which led to a fall and subsequent fractures. This resulted in a finding of harm for resident 5. Resident identifiers: 5. Findings included: Resident 5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included multiple sclerosis, wedge compression fracture of third lumbar vertebra, paraplegia, and neuromuscular dysfunction of bladder. Resident 5's medical record was reviewed on 12/22/25. A progress note dated 11/15/25 at 12:12 PM stated Aide came to nurse stating that [resident 5] was on the floor, nurse found her on her side next to her bed. She stated she rolled to be changed and was rolled too far and rolled off the bed. Scratches on face from metal side rail seen on face. When this nurse said she…

  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 before2023-11-08 · 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, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 3 sampled residents, a resident that was a quadriplegic received second degree burns on his body after being served hot water by a Certified Nursing Assistant (CNA) and the resident was not supervised while drinking the hot water. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, quadriplegia, type 1 diabetes mellitus, neuromuscular dysfunction of bladder, anxiety disorder, and burn of unspecified body region. Resident's medical record was reviewed on 11/8/23. On 11/18/22, a Hot Beverage Evaluation documented that resident 1 DOES NOT demonstrate the ability to self serve hot liquids, but wishes to have hot liquids…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-05-23 · 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, the facility did not ensure each resident received adequate supervision and services to prevent accidents. Specifically, for 1 out of 34 sampled residents, one resident sustained a skin tear to his face after falling off the bed during wound care. Resident identifier: 75. Findings include: Resident 75 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, osteomyelitis of vertebra, sacral and sacrococcygeal region, stage 4 pressure ulcer, acute respiratory failure, contracture of muscle (multiple sites), dependence on respiratory (ventilatory) status, tracheostomy status, severe protein-calorie malnutrition, need for assistance with personal care, bed confinement status, and cognitive communication deficit. Resident 75's medical records were reviewed on 5/18/22. A quarterly Minimum Data Set assessment dated [DATE], revealed that resident 75 required total dependence with two plus persons physical assistance for bed…

  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 before2026-02-12 · 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 observation, interview, and record review, it was determined that, for 1 out of 30 sampled residents, the facility failed to ensure that each resident's environment remained as free of accident hazards as possible, and received adequate supervision and assistance with devices to prevent accidents. Specifically, a resident who had significant dysphagia was coughing while eating with no staff supervision or assistance. Resident identifier: 122.Findings included:On 2/10/26 at 12:26 PM, resident 122 was observed sitting upright in his wheelchair at a table and eating lunch in the dining room, staff member 1 was sitting with him. Resident 122 had a productive wet cough while he was drinking his milk. At 12:27 PM, staff member 1 got up, walked across the large dining room, got a clothing protector, and then returned and put the clothing protector on resident 122 and sat down next to him. Resident 122 was observed to have a productive wet cough after drinking milk. He then ate a spoonful of what looked like…

  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 before2026-02-12 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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 failed to ensure 1 out of 30 residents receiving a tube feeding received appropriate treatment and services to prevent complications. Specifically, observations revealed the tube feeding was not infusing at the rate prescribed by the provider. Resident identifier: 90 Findings included: Resident 90 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spastic quadripalegic cerebral palsy, epilepsy, gastrostomy and dysphagia. Resident 90 was NPO (nothing by mouth).A physician order dated 9/19/25 documented, Isosource 1.5 CAL (calorie) 0.07 G (gram) - 1.5 Liquid. Give 40 ml/hr (milliliter/hour) via G-Tube [gastrostomy tube] two times a day for Nutrition Tube Feed to run continuously X (times) 22 hrs (hours)/day with water flushes of 45mL/hr x 22 hours.On 2/9/26 at 8:50 AM, an observation was made of the tube feeding at resident 90's bedside. The tube feeding pump was infusing at 34 ml/hr. A sticker was observed…

  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 before2026-02-12 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  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 provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 30 sampled residents, a resident who received medication for diabetes mellitus did not have those medications available from the pharmacy for administration. Resident identifier: 97. Findings included: On 2/9/26 at 9:38 AM, an interview was conducted with resident 97 and he stated that he had not received his GLP1 (glucon-like peptide-1) shot (a medication for diabetes) that was due three days ago. Resident 97 stated he was told by staff that it was always given late because the pharmacy did not deliver it.Resident 97's medical record was reviewed from 2/9/26 through 2/12/26.Resident 97 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy and chronic kidney disease.The current physician's order dated 2/9/26 at 2:43 AM indicated, Tirzepatide Subcutaneous Solution…

  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 · D2026-02-12 · tag F0825 — isolated
  Provide or get specialized rehabilitative services as required for a resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that, for 1 out of 30 sampled residents, the facility failed to provide the required specialized rehabilitation services, speech-language pathology. Specifically, one resident experienced a change in his eating abilities and speech therapy was not notified. Resident identifier: 122. Findings included: On 2/10/26 at 12:26 PM, resident 122 was observed sitting upright in his wheelchair at a table and eating lunch in the dining room, staff member 1 was sitting with him. Resident 122 had a productive wet cough while he was drinking his milk. At 12:27 PM, staff member 1 got up, walked across the large dining room, got a clothing protector, and then returned and put the clothing protector on resident 122 and sat down next to him. Resident 122 was observed to have a productive wet cough after drinking milk. Resident 122 then ate a spoonful of what looked like mashed potatoes with gravy and had another productive wet cough. At 12:34 PM, resident 122…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · 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 interview and record review it was determined, for 1 out of 30 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, blood sugar results were not recorded in the medical record for a resident who was given unprescribed insulin. Resident identifiers: 126. Findings included: Resident 126 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis of the right dominant side, dysphagia, acute kidney failure and chronic congestive heart failure. Resident 126's medical record was reviewed on 2/11/26. A progress note dated 11/23/25 at 8:35 AM documented, Med [medication] error, Pt [patient] mistakenly given 50 units glargine insulin. Pt is t2 [type 2] diabetic. Called DON [Director of Nursing], and [medical provider]. Will hold dapagliflozin and monitor BG [blood glucose] every…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-12 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, the facility did not implement policies to address the underlying cause of the problems or identify how corrective actions were taken and monitored in regard to feeding tubes. Resident identifier: 90 Findings included: During the previous recertification survey completed on 1/11/24, Federal tag 693 was cited at a D level for feeding tube noncompliance. Resident 90 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, spastic quadripalegic cerebral palsy, epilepsy, gastrostomy, and dysphagia. A physician order dated 9/19/25, documented, Isosource 1.5 CAL (calorie) 0.07 G (gram) - 1.5 Liquid. Give 40 ml/hr (milliliter/hour) via G-Tube [gastrostomy] two times a day for Nutrition Tube Feed to run continuously X (times) 22 hrs (hours)/day with water…

  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 · D2026-02-12 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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 and interview, the facility failed to ensure that an emergency call system was available and accessible in 5 out of 5 public and staff-accessible restrooms located in common areas used by residents. This failure created a risk that residents who utilized these restrooms would be unable to summon staff assistance in the event of an emergency or fall.Findings included: On 2/9/26 at 9:08 AM, an observation was made of the public restroom located in the Winder Lane hallway; the restroom was accessible to the public and a call light was not located within.On 2/9/26 at 9:09 AM, an observation was made of the public restroom located in the [NAME] Blvd (Boulevard) hallway, adjacent to the conference room; the restroom was accessible to the public and a call light was not located within.On 2/12/26 at 9:40 AM, an observation was made of the public restroom near the door labeled, About Hair; the restroom was accessible to the public and a call light was not located within.On 2/12/26 at 9:46 AM, an…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-30 · 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

  Based on interview, observation, and record review, it was determined that the facility failed to adhere to its established infection prevention and control program. Specifically, a staff member was observed not to wash or sanitize their hands between resident rooms. On June 26, 2025 at 10:50 AM, the surveyor observed certified nursing assistant (CNA) 1. CNA 1 exited a resident's room designated by posted signage for enhanced barrier precautions. The displayed signage required hand hygiene upon entry and exit, as well as the use of gowns and gloves for high-contact resident care, including tasks such as dressing, bathing, transferring, linen changes, hygiene, and toileting assistance. CNA 1 was observed to be carrying a bag of garbage, which appeared to be soiled briefs or linens, and a water mug. After CNA 1 handed the mug to another staff member and discarded the garbage, CNA 1 did not perform hand hygiene. Subsequently, CNA 1 entered a different resident's room without sanitizing hands prior to entry. The surveyor interviewed CNA 1 on June 26, 2025, at 1:05 PM. CNA 1 stated that…

  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 · D2024-01-11 · 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

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assess 1 (Resident #74) of 10 sampled residents to ensure the resident was safe to self-administer inhaled medications. Finding included: A review of a facility policy titled, Resident Self-Administration of Medication, revised in June 2023, revealed, It is the policy of this facility to support the resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The policy revealed 1. Each resident is offered the opportunity to self-administer medications during routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for…

  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 · D2024-01-11 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review, it was determined the facility failed to develop a care plan for 1 (Resident #80) of 7 sampled residents who were dependent on respiratory ventilators. Findings included: A review of a facility policy titled, Comprehensive Care Plans, revised in June 2023, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents' comprehensive assessment. An observation of Resident #80 on 01/08/2024 at 10:58 AM revealed the resident had a tracheostomy and was utilizing a mechanical ventilator. A review of Resident #80's Face Sheet revealed the facility admitted the resident on 06/11/2022. Per the Face Sheet, the resident had diagnoses that included acute respiratory failure, dependence on a respiratory ventilator, a tracheostomy (a surgical opening through the neck into…

  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

“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

$20,318 in federal fines across 1 penalty.

• $20,318 — penalty dated 2023-10-26

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 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 34 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 $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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