Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society -- Fort Collins Village during CMS and state inspections, most recent first.
A resident with a contracted left hand and multiple chronic conditions did not have a physician order, care plan interventions, or Kardex guidance for a palm protector used to manage the contracture. Surveyors observed the palm protector was inconsistently worn and sometimes left on the resident’s table, while staff reported there were no CNA prompts and the DON could not explain why the order and documentation were missing.
Failure to address depression, suicidal ideation, and behavioral symptoms: A resident with dementia and depression expressed feeling better off dead and had documented suicidal thoughts, but the record did not show a suicide lethality assessment or scheduled mental health follow-up. Another resident with dementia, anxiety/depression, and psychotropic use repeatedly called out for help, yet staff did not consistently respond, sleep hours were not monitored, and the chart lacked consistent documentation of behavior interventions, effectiveness, and IDT review of psychotropic use.
Hospice Communication and Documentation Gaps: A resident with dementia, Parkinson's disease, cerebral ischemia, and severe cognitive impairment was receiving hospice services, but the facility did not document the hospice agency's visits or the care provided in the EMR. Staff interviews showed the CNA, LPN, and interim DON did not know when hospice staff came, how often they visited, or what specific services were provided, and the hospice RN said visit notes were kept only in the hospice agency's EMR and not shared with the facility.
Failure to monitor long-term antibiotic use: The facility did not establish an effective ABX stewardship process for two residents receiving prophylactic ABX for UTI prevention. One resident was on daily cephalexin and another was on daily ciprofloxacin, and both orders lacked a stop date or duration. The EMR did not show physician justification, IP ABX use assessment, or McGeer criteria documentation for either resident, and one resident was not included in infection surveillance while a pharmacist note flagged prolonged prophylactic ABX use.
Failure to Provide and Document Palm Protector Use for Contracture Management
Penalty
Summary
The facility failed to ensure a resident with limited ROM received appropriate treatment and services to increase ROM and prevent further decrease in ROM. Resident #43, who had diagnoses including type 2 diabetes, blindness in one eye, fibromyalgia, and chronic congestive heart failure, was cognitively intact and dependent on staff for toileting hygiene, lower body dressing, footwear, and transfers. Surveyors observed that the resident’s left hand was contracted and she was unable to extend all of her fingers. Record review showed the resident’s care plan documented a contracture, but it did not list interventions for managing the contracture. The September 2025 CPO did not include a physician’s order for a palm protector. OT notes showed the first palm protector was provided on 7/7/25 after the resident complained of left hand pain rated 8 out of 10, and OT placed the palm guard on the left hand to protect it and keep the hand in a better position. However, the care plan did not specify how often or how long the palm protector should be worn, and the Kardex did not include information about the hand brace or palm protector. During observations, the resident was sometimes wearing the palm protector and at other times it was not on her hand and was found on her table. The resident stated she sometimes had her brace and that it had disappeared the other night while therapy was working on finding a new one. Staff interviews confirmed there was no physician’s order for the palm protector, no current pop-up task for CNAs, and the interim DON did not know why the resident did not have an order or why the care plan was not updated. OT also stated that best practice would be to measure contractures on admission and that the therapy team had offered items to prevent contractures, but the resident did not want them and this should have been documented.
Failure to address depression, suicidal ideation, and behavioral symptoms
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with depression and suicidal ideation. Resident #70 had diagnoses including dementia, chronic myeloid leukemia, depression, and insomnia, and the MDS showed severe cognitive impairment with PHQ-9 scores indicating mild depression. The resident told staff he was unhappy at the facility, had no family visits, and would talk to a professional if given the chance. A physician note documented worsening depression, feelings of worthlessness, fleeting suicidal thoughts, and thoughts of jumping in front of traffic or cutting his artery with a hacksaw, with recommendations for increased safety checks and mood reassessment after transfer. Despite these findings, the record did not show that a suicide lethality assessment was completed after the PHQ-9 indicated thoughts of being better off dead or hurting himself. The record also did not show that the resident was scheduled to be seen for depression and suicidal ideation. Although the social services director stated she talked with the resident after he endorsed feeling better off dead and said she would complete a suicide ideation assessment and document the conversation, she later could not find a progress note documenting that discussion. Staff interviewed said they were not aware of signs or symptoms of depression or a history of suicidal ideation for the resident. The facility also failed to ensure appropriate treatment and services for another resident with psychiatric and behavioral symptoms. Resident #10 had diagnoses including dementia, mixed anxiety and depressed mood, insomnia, and major depressive disorder, and was receiving an antidepressant, antipsychotic, and Depakote. Her care plans identified yelling out, banging on the wall, and calling out for help, with interventions listed for reassurance, redirection, comfort measures, and assessment of basic needs. During observation, she repeatedly called out for help and staff did not enter the room to determine what she needed. The record also failed to show that her hours of sleep were monitored while she was receiving antidepressant medication, and there was no consistent documentation of what interventions were attempted for her behaviors or whether they were effective. The record further failed to show that the interdisciplinary team met to review her psychotropic medications, the behaviors being monitored, the non-pharmacological interventions used, or her response to those interventions.
Hospice Communication and Documentation Gaps
Penalty
Summary
The facility failed to ensure hospice services provided to one resident met professional standards and principles applicable to individuals providing services in the facility. The resident had diagnoses including dementia, Parkinson's disease, cerebral ischemia, cervical disc degeneration, osteoporosis, anxiety, anemia, and hypertension, and an MDS assessment showed severe cognitive impairment with a BIMS score of 3 out of 15. The resident required maximum assistance with ADLs and had deficits related to incontinence, activity intolerance, aggressive behavior, confusion, dementia, and limited mobility, and was receiving hospice services for end-of-life comfort care. Record review showed the resident had a physician order for hospice care and an end-of-life care plan that listed the hospice agency's phone number, but the care plan did not include interventions for coordinating the resident's specific needs with hospice staff or documentation of the specific care needs the hospice company would provide. The resident's EMR also did not contain documentation of hospice visits or what care was provided during those visits. The hospice RN stated she documented her notes in the hospice agency's iPad and that the notes were sent to the hospice agency, but she did not share her visit notes with the facility and said the notes were only documented in the hospice agency's EMR. Interviews with facility staff showed they did not know when hospice staff came to provide care, how often hospice nurses or hospice CNAs visited, or what specific services were provided. A CNA stated hospice staff might assist with ADLs or bathing but he did not keep track of hospice care provided. An LPN said she would call the hospice agency for questions or changes in condition, but she did not have a reference form for who and when hospice provided care and did not have access to hospice notes. The interim DON said communication with hospice occurred by phone, but she did not know the exact services provided, which hospice discipline provided them, or how often services were provided to the resident.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two residents receiving long-term antibiotics for UTI prophylaxis. The report states that the facility did not track and monitor the use of long-term antibiotics for these residents, and that the antibiotic stewardship policy was intended to guide antibiotic stewardship plans, decrease MDRO incidence, promote appropriate use, and provide standard definitions for initiating antibiotics. One resident, who had CHF, atrial flutter, CKD, hyponatremia, urgency of urination, and overactive bladder, had been ordered cephalexin 250 mg daily for UTI prophylaxis since 12/9/22. The order did not include a stop date, and the resident’s EMR did not contain documentation of the physician’s justification for the long-term antibiotic use. The EMR also did not show that the IP completed an antibiotic use assessment or documented McGeer’s criteria to justify the order. Although infection surveillance documents identified residents with active infections, this resident was not included, and a pharmacist note documented prolonged prophylactic antibiotic use since December 2022 with increased risk of resistance and C. difficile infection. The second resident, who had vascular dementia, atrial fibrillation, prediabetes, muscle weakness, and lack of coordination, had been ordered ciprofloxacin 250 mg in the evening for UTI prophylaxis since 2/18/24. The order also lacked a duration, and the EMR did not contain documentation of the physician’s justification for the long-term antibiotic use or evidence that the IP completed an antibiotic use assessment or documented McGeer’s criteria. A pharmacist note identified the ciprofloxacin as a long-term antibiotic and stated that evidence supporting prophylactic antibiotic use for recurrent UTI in older adults was lacking, but the record did not show that the facility reviewed the long-term use for this resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Collins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lemay Avenue Health And Rehab Llc | 2.4 mi | ★★★★★ | 7 | 0 |
| Center At Rock Creek, Llc | 4.2 mi | — | 0 | 0 |
| Centre Avenue Health And Rehab Llc | 4.2 mi | ★★★★★ | 1 | 0 |
| Columbine West Health And Rehab Llc | 4.3 mi | ★★★★★ | 0 | 0 |
| Creekside Village Rehabilitation And Nursing Llc | 5 mi | ★★★★★ | 36 | 3 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.