Average — CMS composite of the measures below.
A standard survey is most likely before 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 Holly Heights Care And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program, resulting in ongoing mouse activity in multiple resident rooms and hallways. A resident’s representative reported repeated sightings of mice and mouse droppings in a resident’s dresser, clothing, and bed, and personally cleaned and laundered the affected items after submitting multiple grievances. The NHA delayed action after the initial grievance and arranged for a pest control contractor that implemented a trapping plan limited to one unit, despite staff and residents on other units reporting frequent mouse sightings. A pest control specialist confirmed a delay between contract signing and trap placement and restricted the initial mitigation to one side of the building, while residents and staff described mice being caught in bathrooms, rooms, dirty clothes bins, and running in hallways on other units, and a live mouse was directly observed under a resident’s bed during the survey.
The facility did not inform several residents or their representatives about hospice care options before sharing their information with a hospice agency. Instead, the hospice agency contacted the families directly, causing confusion and concern. Staff interviews confirmed that the expected process was not followed, and documentation of prior discussions was lacking.
Three shower rooms were found to be unsanitary, with surveyors observing dirty towels, empty bottles, debris, and strong odors. A resident's representative reported seeing feces and unclean conditions in the shower area. Staff interviews revealed inconsistent cleaning practices, with CNAs and housekeepers not maintaining the expected level of cleanliness.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, or serve food according to professional standards, as observed by surveyors.
Surveyors identified that the facility did not maintain a safe and functional environment, as evidenced by a leaking kitchen handwashing sink with water collecting in a bucket and multiple damaged handrails throughout the building. The maintenance director reported ongoing issues with both the sink and handrails, including repeated leaks and persistent damage from resident contact, resulting in hazards such as exposed sharp edges and missing sections.
A facility failed to ensure nourishing snacks were available when residents requested them and for residents on diabetic diets. Residents said the units often ran out of snacks in the evening and that staff told them snacks were not available, while one resident said there were no snack options that fit a diabetic diet. Observations found limited items in nourishment refrigerators and cabinets, and staff, including an LPN, CNAs, the dietary manager, the RD consultant, and the DON, acknowledged that diabetic snacks were not consistently available on the units and sometimes had to be obtained from the kitchen.
A resident's personal funds account was not reimbursed to the estate within the required timeframe after death. The facility failed to use the correct contact information available in the admission agreement, sent a refund check to an outdated address, and did not make further attempts to contact the representative, resulting in the estate not receiving the funds.
Psychotropic medication use lacked adequate documentation for a resident with dementia and Huntington's disease. The resident was receiving multiple psychotropic medications, including an antidepressant, antianxiety medication, anticonvulsant, and antipsychotics, but the chart did not show consistent behavior monitoring orders, documented behaviors to justify additions or dose increases, or physician risk/benefit rationale. Consents for some psychoactive medications were also obtained after the medications had already been in use.
A resident on Eliquis had a wrist bruise observed, but nursing anticoagulant monitoring did not document the skin change or notify the provider until later. Another resident with risk factors for skin breakdown did not receive required weekly skin assessments for several weeks before MASD was identified.
A resident with cellulitis and sepsis, who was cognitively intact but identified as at risk for impaired thought processes, was allowed to smoke without a documented smoking assessment. Staff reported the facility was non-smoking but still kept the resident’s cigarettes and, at times, his lighter. The resident was observed smoking less than three feet from a door and later in the front driveway/parking lot, which the NHA identified as facility property.
BiPAP Machine Not Cleaned or Sanitized: A resident with COPD, chronic respiratory failure with hypoxia, and supplemental O2 dependence was observed with a BiPAP machine whose reservoir had visible scale and condensation. The resident said she did not think the machine had ever been cleaned, and the EMR had no documentation of cleaning. The care plan did not address BiPAP use or cleaning, and the DON said the respiratory vendor was supposed to clean the device weekly.
Failure to provide individualized psychosocial care and suicide monitoring for a resident with bipolar disorder, MDD, PTSD, and a history of trauma and suicide attempts. The resident reported worsening depression, high anxiety, intrusive trauma-related thoughts, and minimal relief from current psychotropic meds. Records showed a trauma care plan, mood care plan, and safety plan, but the CPO lacked an order to monitor for suicidal ideation, the behavior plan did not reflect the resident’s specific warning signs and interventions, and staff were not aware of the resident’s suicide history.
An infection control deficiency occurred when an LPN administered medications and water through a resident’s feeding tube without wearing a gown while the resident was on EBP. The resident had an indwelling feeding tube, and the LPN used gloves but no gown during the care. Interviews confirmed staff understood that gown and gloves were required for feeding tube medication administration for residents on EBP.
A resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors was able to leave the facility unnoticed when the front desk was briefly unattended. The absence was not discovered for several hours, and the resident was later found at a hospital with multiple abrasions after traveling several miles on foot.
A resident with severe cognitive impairments and dependent on staff for bathing did not receive scheduled showers during their stay. Despite facility policies requiring documentation of shower refusals, there was no record of the resident receiving or refusing showers. Staff interviews confirmed the lack of documentation, and the DON acknowledged the issue, noting the resident's wife's concerns about the need for forced showers.
The facility failed to provide individualized recreational activities for three residents, as outlined in their care plans. Despite the need for one-on-one visits to support their well-being, no such visits were documented over several months. The Activity Director admitted to not completing these visits, and the administration was aware but had not implemented corrective measures.
Failure to Maintain Effective Pest Control Across All Units
Penalty
Summary
The facility failed to maintain an effective pest control program to keep resident rooms free from mice on two of three units. The facility’s pest control policy required an environment free of pests, frequent contracted treatments, allowance for additional visits when problems were detected, and prompt reporting of pest control problems by staff. Despite this, a grievance submitted at the end of December documented mouse feces in a resident’s dresser drawers and on the resident’s clothes and bed, with the resident’s representative personally cleaning the drawers and taking clothes home to wash. The representative reported seeing mice frequently in the resident’s room and stated that there were no traps in the room as of a few days prior to the interview, and that management had provided little to no response despite multiple grievances. The NHA acknowledged receiving the written grievance about mice several days after it was filed and did not initiate housekeeping inspection of the affected unit until nearly a week after the grievance date. The NHA reported that the pest control company had previously been visiting only once per month and that an additional extermination contract was signed later, after the grievance, with the pest control company assessing the building and determining that mice were present only on one of three units. The pest control specialist confirmed that although the contract for extra work was signed, there was about a one‑week delay before traps were actually set, and that the initial mitigation plan and trap placement were limited to a single unit (rooms four through 30) on one side of the building. The specialist also stated that he had identified likely entry points near heater and air conditioner units but had not yet communicated these locations to the NHA. Multiple residents and staff reported ongoing mouse activity outside the unit initially targeted by the pest control plan. One resident reported a mouse caught in her bathroom and another reported a mouse caught in her room, both on a different unit than the one included in the initial mitigation plan, and stated that mice remained a problem throughout the facility despite frequent complaints. During an interview with one of these residents, a live mouse was observed under the resident’s bed, stuck on a glue board and squealing, and the NHA removed it from the room. Additional staff interviews revealed that a housekeeper had found a live mouse in a dirty clothes bin on that same hallway the previous week, a CNA had found and discarded a mouse in the same resident’s room, and an RN reported seeing mice a couple of times per week on her unit, with each sighting entered into the computer system for maintenance. Other residents reported often seeing several mice running up and down the hallway at night and “a lot of mice” in the hallway, including many mice seen just the prior week, demonstrating that mice activity was occurring on more than one unit while the facility’s pest control efforts remained limited and delayed.
Failure to Inform Residents or Representatives Prior to Hospice Referral
Penalty
Summary
The facility failed to inform four residents or their representatives about hospice care options prior to sharing their information with a hospice agency. According to the facility's Resident Rights policy, residents are to be fully informed in advance about care and treatment options and participate in planning their medical treatment. However, for four residents with severe cognitive impairments and complex medical conditions, there was no documentation in their electronic medical records indicating that the facility had discussed hospice services with them or their powers of attorney before the hospice agency was contacted. Interviews with the residents' representatives revealed that they were first contacted by the hospice agency, not the facility, regarding hospice services. These representatives expressed confusion and concern about how the hospice agency obtained their contact information and were disturbed by the unexpected nature of the calls, especially given the sensitive topic of end-of-life care. In some cases, representatives believed the calls could be attempts at financial abuse or posed a risk to the residents' safety, as they had not previously discussed hospice care with the facility. Staff interviews confirmed that the interdisciplinary team (IDT) identified residents who might benefit from hospice and that the facility's process should involve notifying residents or their representatives before contacting hospice providers. Nursing staff and the DON acknowledged that the facility did not always communicate with families prior to involving hospice agencies, and that this was a lapse in procedure. The hospice director also stated that families should be educated by the facility first, but admitted to being the initial point of contact for many families.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
Surveyors observed that three out of four shower rooms in the facility were not maintained in a safe, clean, and sanitary condition. Specific findings included empty shampoo and body wash bottles, piles of wet towels, and a strong smell of urine in one shower room. The inside of tubs contained bags of wet towels, empty bottles, black grime, hair, and unidentified trash. In another shower room, resident equipment such as wheelchairs, walkers, and bedside commodes blocked access to the shower stall. These conditions were directly observed by surveyors during their inspection. Interviews with a resident representative revealed that she had previously observed feces on the floor and in the shower, along with used towels and empty bottles left behind, resulting in a very bad odor. Staff interviews indicated inconsistent cleaning practices, with CNAs expected to clean after each use and housekeepers to deep clean weekly. The DON stated that tubs were not currently in use, but if a resident requested a bath, the tub would need to be checked and cleaned first. Despite these expectations, the observed conditions showed that the shower rooms were not being kept clean and sanitary as required.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Maintain Safe and Functional Environment Due to Leaking Kitchen Sink and Damaged Handrails
Penalty
Summary
The facility failed to maintain a safe, sanitary, functional, and comfortable environment for residents, staff, and the public. During an initial walk-through of the kitchen, a leaking P-trap pipe was observed under the handwashing sink, with water collecting in a nearly full three-gallon bucket. Staff interviews revealed conflicting accounts regarding the duration of the leak, with a dietary aide stating it began that week, while the maintenance director indicated the issue had persisted for several months, including leakage into the subfloor. The maintenance director also reported that a replacement P-trap pipe began leaking again about a month prior to the observation. Additionally, the facility failed to ensure that handrails were in safe, operational, and functional condition. Observations showed that several handrails in the facility were covered with gray electrical tape and yellow caution tape, had cracked sections with exposed sharp edges, and in some areas, the curved connecting sections were missing entirely. The maintenance director was unable to specify how long the handrails had been damaged and acknowledged that the damage was an ongoing issue due to residents bumping into the handrails, which created hazards for residents.
Snacks Not Consistently Available for Resident Requests and Diabetic Diets
Penalty
Summary
The facility failed to ensure residents received substantial nourishing snacks according to their preferences and needs, including snacks upon request and nourishing snacks for residents on diabetic diets. During a resident group interview, six alert and oriented residents said the units often ran out of snacks in the evening, that staff told them snacks were not available when requested, and that there were no snack options that met diabetic needs. One resident said they were unaware snacks were available in the evening, and another said there were no snack options aligned with a diabetic diet. Observations of the nourishment refrigerators and surrounding cabinets on the Riverwalk, Summit Ridge, and Highline Creek units showed limited and inconsistent snack availability. At various times, the refrigerators contained items such as sandwiches, milk, yogurt, ice cream cups, and a few unlabeled or unidentified foods, while the cabinets contained assorted cookies, crackers, and rice crispy squares; no clearly identified diabetic snack options were observed in some areas. Staff interviews confirmed that dietary staff brought snacks to the nourishment refrigerators daily, but diabetic snacks were sometimes limited to fruit cups or had to be obtained from the main kitchen. An LPN, CNAs, the dietary manager, the RD consultant, and the DON all acknowledged that diabetic residents did not consistently have appropriate snacks readily available on the units and that staff sometimes had to seek snacks from the kitchen when needed.
Failure to Timely Reimburse Resident Funds to Estate After Death
Penalty
Summary
The facility failed to accurately manage and reimburse the personal funds account of a resident after the resident's death. The resident's representative had opened a trust account upon admission, and the resident passed away before any funds were used. Despite the representative's repeated attempts to contact the facility regarding the refund, there was no documentation in the electronic medical record indicating that the facility had attempted to return the funds or contact the representative after the resident's death. The admission agreement contained the correct contact information, but the face sheet had an incorrect phone number for the representative. The business office manager initially stated that the resident did not have an account, but later confirmed the account existed and said a refund check would be sent. The facility sent a check to an old address, which was returned, and made no further attempts to contact the representative, despite having the correct information in the admission agreement. This resulted in the resident's estate not being reimbursed within 30 days as required.
Psychotropic Medication Use Lacked Supporting Documentation and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that one resident was free from chemical restraint and received the least restrictive approach for his needs. Resident #34, who was under 65 years old and had diagnoses of dementia and Huntington's disease, was cognitively intact with a BIMS score of 15 out of 15 and had no behaviors or delusions documented on the 6/30/25 MDS. His care plans identified use of multiple psychotropic medications, including an anticonvulsant, antianxiety medication, antidepressant, and antipsychotic medication, with behavior monitoring orders intended to track specific symptoms such as pacing, wandering, disrobing, agitation, paranoia, and verbal aggression. Record review showed multiple psychotropic medication changes without supporting documentation of the resident’s behaviors or physician-documented risk versus benefit rationale. The resident’s regimen included sertraline, divalproex, alprazolam, propranolol, olanzapine, risperidone, and later clozapine, with several dose increases and additions over time. The chart did not contain documented behaviors in the progress notes to justify some medication additions or increases, including the initial addition of risperidone, the restart and later increase of risperidone, the increase of divalproex, and the addition of clozapine. The EMR also failed to show risk versus benefit documentation by the physician to support continued use or escalation of the psychotropic regimen. The behavior monitoring physician’s orders did not consistently reflect the resident’s specific behaviors. Although staff later described paranoia, refusal to work with male staff, yelling, closing his door, and other behavioral concerns, the orders did not always include those specific behaviors, such as paranoia about poisoning or paranoia toward males. MAR/TAR documentation also showed inconsistencies, including behavior episodes without documented interventions and episodes where no effective interventions were recorded. In addition, psychoactive medication consents for divalproex and sertraline were obtained on 8/20/25 even though those medications had been started much earlier, and staff interviews confirmed that behavior monitoring, individualized interventions, and risk/benefit documentation were expected but were not consistently present in the record.
Failure to document bruising during anticoagulant monitoring and to complete weekly skin assessments
Penalty
Summary
The facility failed to provide treatment and care according to orders and resident needs for two residents. One resident was receiving anticoagulant therapy for atrial fibrillation and had a documented bruise on the right wrist that was observed by surveyors. The resident stated the bruise had been present since the previous week and could not recall how it occurred. Although the resident was on Eliquis and had an anticoagulant monitoring order requiring staff to monitor, document, and report signs of anticoagulant complications, the record did not show documentation of the bruise or notification to the provider until the survey period. The resident’s care plan directed staff to monitor and report bruising and other signs of anticoagulant complications. The medication record showed anticoagulant monitoring was marked completed on both day and night shifts on 8/18/25 and 8/19/25, but the electronic record did not document the wrist bruise during those checks. When the skin issue was later documented, the note described discoloration at both medial wrists and recorded measurements, but the bruise had already been observed earlier and had not been identified in the earlier monitoring documentation. A second resident had weekly skin assessments that were not completed between 6/21/25 and 7/20/25. This resident had diagnoses including Parkinson’s disease, depression, and bipolar disorder, and was documented as at risk for pressure injuries. Earlier skin documentation showed the resident had moisture associated skin damage on the right gluteal fold and later a non-pressure skin ulcer assessment identified MASD on the buttocks with drainage. The record also showed that the required weekly skin evaluations were not completed during the intervening weeks, and there were no documented refusals for the missed assessments.
Failure to Assess Smoking Safety and Prevent Smoking in Prohibited Areas
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards and that adequate supervision was provided when Resident #68 was allowed to smoke without a documented smoking assessment and was observed smoking in prohibited areas. Resident #68 was admitted with diagnoses including cellulitis of the left lower limb and sepsis, and the 8/18/25 MDS showed he was cognitively intact with a BIMS score of 13 out of 15. The care plan identified risk for impaired cognitive function and/or impaired thought processes related to psychotropic drug use, with interventions for step-by-step instructions as needed. Record review and interviews showed the resident was repeatedly seeking cigarettes and leaving the facility to smoke. Nursing notes documented that he was agitated on admission and trying to leave to smoke, and that he later asked for cigarettes more often and would ask to go out if he did not get them. Staff reported the facility did not complete smoking assessments because it was a non-smoking facility, yet they allowed smoking residents to keep cigarettes and, in some cases, a lighter. The resident was observed smoking less than three feet from a door on a side patio, with cigarette odor present inside the dining room, and later smoking in the front driveway/parking lot area, which the NHA identified as part of the facility property. A smoking assessment was not found in the EMR until during the survey, when it indicated the resident could smoke safely and had agreed to smoke off the facility property.
BiPAP Machine Not Cleaned or Sanitized
Penalty
Summary
The facility failed to ensure Resident #48 received respiratory care consistent with professional standards or practice when her BiPAP machine was not cleaned and sanitized. Resident #48, who was cognitively intact and had diagnoses including COPD, chronic respiratory failure with hypoxia, type 2 diabetes mellitus, major depressive disorder, and dependence on supplemental oxygen, was observed with her BiPAP machine and tubing on top of her nightstand and the mask on her bed. The reservoir in the BiPAP machine had a layer of scale covering the bottom, and on a later observation it also contained condensation inside. The resident stated she did not think the BiPAP machine had ever been cleaned and said she had been told a nurse should clean it. Record review showed the resident’s care plan addressed altered respiratory status and oxygen therapy, but did not include a care plan or interventions for BiPAP administration, use, or cleaning. The physician’s order directed that the BiPAP run overnight and that oxygen be connected to the concentrator and BiPAP once daily, but it did not include cleaning instructions. The electronic medical record did not document that the BiPAP had been cleaned. The DON stated the respiratory services vendor was supposed to clean the BiPAP once a week, and that the vendor cleaned out the resident’s BiPAP machine during the survey after scale was found inside.
Failure to Monitor and Individualize Care for a Resident With Depression, Trauma, and Suicidal History
Penalty
Summary
The facility failed to ensure that a resident with bipolar disorder, major depressive disorder, suicidal ideations, a history of suicide attempts, PTSD, and a history of sexual trauma received individualized treatment and services to support emotional and psychosocial wellbeing. The resident was cognitively intact, reported feeling down, depressed, and hopeless on the MDS, and described ongoing distress related to living in the facility, feeling more independent than other residents, and struggling with depression since admission. Record review showed the resident had trauma-related care planning that identified risk for re-traumatization due to childhood sexual abuse and recent sexual abuse, along with a mood care plan that identified depression, bipolar disorder, and adjustment disorder. The mood plan included monitoring for suicidal risk behaviors and signs of mania or hypomania, and the resident had psychotropic medications ordered for bipolar disorder and depression. However, the August 2025 physician orders did not include an order to monitor for signs and symptoms of suicidal ideation, despite the resident’s history and the care plan’s focus on suicide risk. Progress notes documented worsening depressive symptoms, high anxiety, PTSD symptoms, intrusive thoughts related to the perpetrator, and the resident’s report that her medications were providing minimal relief. A psychiatric NP and psychiatrist both noted that the resident’s regimen appeared suboptimal and recommended medication changes, including increasing Latuda and changing Duloxetine to Effexor, and one note also recommended monitoring for suicidal ideations. The resident also reported numerous prior psychiatric hospitalizations for depression and suicidal thoughts and a past suicide attempt. Staff interviews showed nurses and CNAs were not aware of a suicide history for the resident, and the social services director stated she was not monitoring for suicidal ideations because the prior psychiatric hospitalization was not considered serious and she assumed staff would identify and report depressive behaviors. The resident’s behavior monitoring and care plan also did not include the specific warning signs and interventions identified in the safety plan, and social service assessments noted a trauma trigger related to gender-specific caregivers without specifying the gender or how the trigger was being addressed.
Infection Control PPE Failure During Feeding Tube Medication Administration
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of four units. The deficiency involved Resident #5, who was on enhanced barrier precautions (EBP) and had a feeding tube, an indwelling medical device identified in the report as a major risk factor for colonization with or acquisition of a multidrug resistant organism (MDRO). During a continuous observation, an LPN entered the resident’s room with medication cups and an irrigation tray kit, donned gloves, repositioned the resident’s clothing to access the feeding tube, and administered water and two medications through the tube. The LPN flushed the tube between and after medication administration but did not put on a gown before providing care to the resident. In interviews, the LPN stated that staff needed to wear a gown, gloves, and a mask when a resident was on EBP, but said she did not wear a gown while administering medications through the feeding tube and did not know whether nursing staff needed PPE during medication administration. The ADON stated that nursing staff should wear a gown and gloves when administering medications through a feeding tube for a resident on EBP.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident assessed as high risk for elopement. The resident, who had diagnoses including Wernicke's encephalopathy, repeated falls, unspecified dementia, somnolence, and alcohol dependence, was known to exhibit exit-seeking behaviors and had verbalized a desire to leave the facility. Despite being identified as a high elopement risk and having a care plan in place, the resident was able to leave the facility unnoticed through the front door. On the day of the incident, the resident exited the building at 3:42 p.m. without staff awareness. The absence was not discovered until approximately two hours later, at which point staff initiated a search inside and outside the facility. The local police, the nursing home administrator, and the director of nursing were notified several hours after the resident's disappearance. The resident was ultimately found at a hospital emergency room nearly ten hours after leaving the facility, having traveled approximately five miles and sustaining abrasions to multiple areas of the body. Interviews and record reviews confirmed that the resident had a history of severe cognitive impairment, frequent wandering, and behavioral disturbances, including agitation and restlessness. The resident had previously demonstrated exit-seeking behavior by pushing on the front door and had required one-to-one supervision at times. On the day of the elopement, the front desk receptionist, whose duties included monitoring the front door, was temporarily away from the desk assisting ambulance workers, during which time the resident left the facility. The facility's failure to maintain adequate supervision and monitoring directly resulted in the resident's elopement and subsequent injuries.
Failure to Document and Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for bathing, received his scheduled showers. The resident, who was over 65 years old and had severe cognitive impairments, was admitted for respite care and had a diagnosis of unsteadiness on his feet, repeated falls, and unspecified dementia. Despite being dependent on staff for showering, there was no documentation to confirm that the resident received or refused showers during his stay from October 9 to October 16, 2024. Interviews with staff revealed that if a resident refused a shower, it was supposed to be reported to the unit manager and documented in the progress notes. However, there was no evidence that this procedure was followed for the resident in question. The Director of Nursing acknowledged that there was no documentation of shower refusals and mentioned that the resident's wife had expressed concerns about the resident needing to be forced to shower. The lack of documentation and adherence to the facility's policy resulted in the failure to provide necessary services for the resident's personal hygiene.
Failure to Provide Individualized Recreational Activities
Penalty
Summary
The facility failed to provide person-centered, individualized recreational activities to meet the needs and interests of three residents, as identified in their comprehensive care plans. These residents were supposed to receive one-on-one activity visits to promote their physical, medical, and psychosocial well-being. However, the facility did not document any such visits for these residents, indicating a lack of adherence to the care plans. Resident #3, who had moderate cognitive impairments and required maximum assistance with daily activities, was identified as needing one-on-one activity visits two to three times per week. Despite this, there was no documentation of any such visits over a six-month period. Similarly, Resident #6, who was cognitively intact but had quadriplegia, was supposed to receive one-on-one visits to discuss current events and reminisce about his travels. He reported not having attended any group activities or received one-on-one visits for over nine months. Resident #8, with moderate cognitive impairment and various physical limitations, was also supposed to receive one-on-one visits focusing on leisure education and games. However, only two visits were documented over a six-month period. The Activity Director admitted to not completing or documenting these visits, acknowledging a failure to follow the residents' care plans. The facility's administration was aware of the issue but had not implemented a performance improvement plan to address the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 477 citations issued within 25 miles in the last 12 months — including the 8 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highline Post Acute | 0 mi | ★★★★★ | 1 | 1 |
| Brookshire Post Acute | 0.6 mi | ★★★★★ | 3 | 1 |
| Amberwood Post Acute | 0.6 mi | ★★★★★ | 4 | 0 |
| Rowan Community, Inc | 0.7 mi | ★★★★★ | 3 | 0 |
| Suites At Clermont Park Care Center, The | 1.1 mi | ★★★★★ | 8 | 0 |
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