Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Green House Homes At Mirasol, The during CMS and state inspections, most recent first.
The facility did not provide adequate responses or follow-up to group grievances raised by residents during council meetings, including concerns about bed-making, mattress quality, and napkin types. Documentation of these concerns and their resolution was incomplete, and staff did not communicate outcomes back to the residents, leaving issues unresolved.
The facility assigned an unqualified staff member to direct its activities program, as the individual lacked the required credentials, experience, and completed training to serve as an activities director. Both the staff member and the administrator confirmed the absence of necessary qualifications, resulting in the activities program not being overseen by a qualified professional.
The facility did not properly monitor or document antibiotic use for three residents, including failure to obtain necessary lab tests before starting antibiotics, lack of risk-benefit assessments for long-term prophylactic antibiotic use, and absence of care plan interventions or periodic reviews as required by facility policy.
Two residents did not receive care in accordance with physician orders and their preferences: one did not have prescribed ace wraps applied for edema, and another continued to receive a daily iron supplement despite elevated ferritin levels and pharmacist recommendations to reduce the dose. Documentation was lacking for care plan interventions, resident education, and physician notifications.
Staff failed to consistently use required PPE, such as gowns, during high-contact care activities for two residents on enhanced barrier precautions, despite clear signage and available supplies. Observations and interviews revealed that gloves were often used, but gowns were rarely worn, even during wound and catheter care. Additionally, the facility lacked documentation and implementation of a water management plan to monitor for Legionella, including regular temperature checks, flushing of low-flow pipes, and staff training.
Failure to Respond to Resident Council Grievances
Penalty
Summary
The facility failed to ensure that residents' group grievances, as raised during resident council meetings, were properly addressed with a response, action, and rationale. Residents expressed concerns about staff not making beds to their preferences, dissatisfaction with the type of mattresses provided, and issues with the napkins used during mealtimes. These concerns were repeatedly brought up in resident council meetings, but residents reported that staff did not follow up with resolutions or communicate outcomes back to them. Review of resident council meeting notes from several months revealed that concerns about mattresses and napkins were documented but not revisited or resolved in subsequent meetings. There was no documentation indicating that the facility reviewed or approved actions related to these concerns, nor was there evidence that residents were informed of any follow-up or resolution. Complaint and concern reports were incomplete, lacking dates, resident identification, and confirmation of satisfaction with the facility's response. Interviews with staff, including the life enrichment director and the nursing home administrator, confirmed that while concerns were discussed in department head meetings, there was no process to communicate responses or resolutions back to the resident council. The staff acknowledged that issues regarding bed-making, napkins, and mattresses remained unresolved, and the required documentation and follow-up as outlined in the facility's grievance policy were not completed.
Unqualified Staff Assigned to Direct Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by regulatory standards. The individual serving as the life enrichment director (LED) had previously worked as a certified nurse aide (CNA) and ward clerk but did not meet the qualifications for an activities director. Specifically, the LED was not a qualified therapeutic recreation specialist, did not have two years of experience in a social or recreational program within the last five years, was not a qualified occupational therapist or occupational therapy assistant, and had not completed a state-approved training course. The LED had only recently started an activities director course, which was not yet completed at the time of the survey. Interviews with the LED and the nursing home administrator (NHA) confirmed that the LED lacked the necessary qualifications and experience to direct the activities program. The NHA acknowledged uncertainty regarding the LED's prior experience and later confirmed that the LED did not meet the required criteria. As a result, the facility did not have a qualified professional overseeing the development, implementation, supervision, and evaluation of the activities program for residents requiring activity and recreational support.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as required, resulting in deficiencies related to the monitoring and documentation of antibiotic use for three residents. For one resident with a history of urinary retention, chronic kidney disease, and benign prostate hyperplasia, an antibiotic was prescribed for a urinary tract infection based on symptoms such as abnormal urine color and strong smell. However, there was no documentation that a urine culture and sensitivity test was performed prior to starting the antibiotic, nor was there evidence that the resident met the facility's criteria for antibiotic initiation. Two other residents were prescribed long-term prophylactic antibiotics: one for an infected knee prosthesis and another for chronic obstructive pulmonary disease (COPD). In both cases, the facility failed to document a risk-benefit assessment by the physician to justify the ongoing use of antibiotics. Additionally, neither resident had a care plan focus or interventions addressing the need for continuous antibiotic therapy, and there was no evidence of monthly assessments or 48-hour time-out reviews to evaluate the appropriateness of continued antibiotic use. Interviews with nursing and pharmacy staff revealed a lack of consistent monitoring practices for residents on antibiotics, with responsibility for oversight often deferred to the prescribing physician. Despite facility policies requiring standardized assessment, documentation, and periodic review of antibiotic use, these processes were not followed or documented for the residents in question. There was also no evidence of physician documentation justifying the long-term use of antibiotics for the affected residents.
Failure to Provide Care According to Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide resident-centered care in accordance with physician orders and professional standards for two residents. For one resident with a diagnosis of edema, staff did not apply ace wraps with kerlix gauze to her legs and feet as ordered by the physician. Observations on multiple days showed the resident without the prescribed compression wraps, and instead, she was found wearing black stockings, which were not in accordance with the physician's order. The care plan for this resident did not include interventions for edema, and there was no documentation of refusal or explanation for the deviation from the prescribed treatment, despite staff claims that the resident sometimes refused the wraps. For another resident, the facility did not follow up appropriately with the physician regarding elevated ferritin levels and the continued administration of an iron supplement. The pharmacist had recommended reducing the iron supplement frequency, but the resident continued to receive it daily for months. Laboratory results showed a ferritin level above the recommended range, but there was no documentation that the physician was notified or that the resident was educated about the risks of continued iron supplementation. Progress notes and the care plan did not reflect the resident's preference to continue the supplement or any education provided, despite staff interviews indicating the resident insisted on taking the iron and was reportedly educated about the risks. In both cases, the facility failed to ensure that care was provided according to physician orders, resident preferences, and professional standards. Documentation was lacking regarding care plan updates, resident refusals, education, and physician notifications. These deficiencies resulted in residents not receiving care and services tailored to their physical, mental, and psychosocial needs as required.
Deficiencies in Infection Control Practices and Legionella Water Management
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, specifically in the use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) and in the implementation of an effective water management plan to monitor for Legionella. Staff did not consistently don gowns when providing direct care, such as wound and catheter care, to residents on EBP, despite clear signage and the availability of PPE outside resident rooms. Interviews with residents and their representatives confirmed that staff often only wore gloves and rarely used gowns during high-contact care activities, even when required by facility policy and CDC guidelines. Direct observation of wound care by the assistant director of nursing (ADON) revealed that a gown was not worn during the procedure, and the ADON later acknowledged this omission. Further interviews with staff indicated a lack of understanding and inconsistent communication regarding PPE requirements for residents on EBP. One CNA stated he was not informed that gowns were required, and the ADON admitted to not following the correct protocol during wound care. The director of nursing (DON) confirmed that EBP should be implemented for residents with MDROs, catheters, open wounds, or PICC lines, but the observed practices did not align with these expectations. The facility also failed to implement an effective water management plan to monitor for Legionella. There was no documentation of regular water temperature readings, flushing of low-flow piping or dead legs, or staff training on Legionella prevention. The maintenance director (MTD) was unaware of the specific requirements for Legionella monitoring and relied on a discontinued external contractor for the water management plan. The nursing home administrator confirmed the absence of documentation for water testing and indicated that the MTD should be involved in water management planning, but no evidence of such involvement or training was provided.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 222 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Loveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society -- Loveland Village | 1.5 mi | ★★★★★ | 15 | 0 |
| Riverbend Health And Rehabilitation Center | 1.8 mi | ★★★★★ | 13 | 0 |
| North Shore Health & Rehab Facility | 3.2 mi | ★★★★★ | 1 | 0 |
| Berthoud Care And Rehabilitation | 5.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society -- Fort Collins Village | 7.6 mi | ★★★★★ | 12 | 0 |
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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.