Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Life Care Center Of Longmont during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, dementia with behavioral disturbance, and severe cognitive impairment was physically restrained during incontinence care when a CNA placed a hand over the resident’s mouth and held the resident’s arms while the resident was yelling and striking out. Staff statements described the resident as combative during care, and the resident’s representative said the event would have been frightening. The care plan addressed confusion, anxiety, and yelling, but did not include interventions for physically aggressive behavior during care.
Insufficient nursing staffing resulted in delayed call light response and missed showers. Residents reported waiting over an hour for help with toileting, transfers, and other needs, and several said showers were not provided as scheduled or were cancelled when staff ran out of time. Observations showed a resident’s call light left unanswered for 25 minutes and another resident waiting for assistance to get out of bed because a nurse could not be obtained. Staff acknowledged that call-offs and high care needs made it difficult to meet residents’ needs on all shifts.
A facility failed to ensure meals were consistently palatable and served at an appetizing temperature. Residents reported cold, bland, hard, or missing food items, including eggs, pancakes, hamburgers, cereal milk, and coffee creamer, and said the menu was repetitive and trays were sometimes forgotten. Surveyors also found a test tray with bland, pasty, and doughy items, and record review showed trays sitting for an extended period with food temperatures dropping before delivery.
Medication carts and storage rooms contained multiple labeling and storage errors, including an opened nitroglycerin bottle without a resident name, an undated Wixela inhaler, undated insulin glargine pens, and tuberculin vials without open dates. Staff also found expired or improperly stored items, including docusate past its expiration date, lidocaine patches for a discharged resident, and other items left in carts despite being personal items or having storage instructions that were not followed.
Failure to Protect Residents from Abuse: A resident with dementia and aggressive behaviors physically abused another resident after entering her room and striking her chest when she tried to help him. In separate incidents, the same resident sexually abused two cognitively impaired residents by placing his hand inside one resident’s pants while she slept and touching another resident’s breast over her clothing in a common area. The report documents prior inappropriate sexual and grabbing behaviors by the assailant and resident-to-resident incidents that occurred despite those known behaviors.
Failure to Report Alleged Physical Abuse: A cognitively intact resident with multiple medical diagnoses reported that another resident entered her room and hit her in the chest after she tried to help him. Staff documented the incident, noted soreness, and placed the other resident on 1:1 supervision, but the facility’s IDT decided it was not reportable because they did not believe there was allegation or intent. The NHA later stated the incident should have been reported to the State Survey Agency.
A facility failed to ensure two residents received scheduled showers needed for ADL support and personal hygiene. One resident with an ankle fracture and another resident with a humerus fracture, heart disease, UTI, and DM both had documented bathing preferences and required assistance, but shower records showed missed or delayed showers with no documented refusals or explanation. Staff and the DON acknowledged the residents should have received regular showers, yet the records did not show that the scheduled bathing occurred as planned.
Failure to Enter and Follow Post-Orthopedic Dressing Orders: A resident with a right ankle fracture returned from an orthopedic visit with instructions for dressing changes, but the orders were not entered into the EMR and the dressing was not changed as directed. The resident reported the dressing remained unchanged until she alerted staff, and the wound care order was not initiated until later during the survey.
A resident with Parkinson’s disease, chronic respiratory failure, MI, AFib, and anticoagulant use was transferred with confusion between a Sara Steady and a Hoyer lift, despite staff records not matching her transfer needs. She reported that a CNA used the sit-to-stand incorrectly, causing pain and bruising across her back and side, and nursing later changed her to a Hoyer lift. The record also showed therapy was not timely notified to review the transfer concern after the bruising occurred.
Delayed Pain Medication Administration: A resident with severe post-surgical knee pain and orders for PRN hydromorphone had repeated pain ratings up to 10/10, but the first dose was not given until many hours after the pain began escalating. The record also lacked timely documentation for Tylenol, and the DON stated the ordered opioid was available and should have been administered when requested.
The facility failed to complete annual performance reviews for three of five CNAs and did not identify their training needs. Record review showed the CNAs’ last evaluations were overdue, and the DON said the SDC tracked employee evaluations while the NHA said all-staff training was done during the annual skills fair.
Medication administration errors exceeded the allowed rate, with surveyors finding a 10.34% error rate. An RN left a resident’s oxycodone at the bedside and did not directly observe the resident take it, and an LPN incorrectly selected propranolol instead of Seroquel, documented Seroquel as given, and later administered only 25 mg of Seroquel instead of the ordered 37.5 mg dose.
An LPN prepared propranolol 20 mg instead of the ordered Seroquel for a resident with dementia and severe cognitive impairment, then documented Seroquel as given on the MAR. The error was identified before the medication was administered, and the DON stated the resident could have had an adverse reaction if propranolol had been given instead of the prescribed medication.
A resident with severe cognitive impairment, Alzheimer's disease, and dementia with psychotic disturbance was admitted to hospice, but the care plan did not include a hospice plan with a delineation of care. Staff gave conflicting accounts about who was responsible for creating the hospice care plan, and the DON acknowledged the resident did not have one.
Survey Results Binder Missing Required Findings: The facility failed to make the most recent survey findings and the last three years of complaint findings fully available for review in the lobby binder. The binder contained older survey findings, but it did not include the most recent recertification survey or the required complaint findings. The NHA stated the most recent survey and complaint findings should have been in the binder and believed they were already there.
A resident with a history of falls and multiple medical conditions experienced a fall during the night, but the facility failed to promptly notify the resident's power of attorney as required by policy. The representative was only informed after the resident became unresponsive and was transferred to the hospital, where a large subdural hematoma was discovered. Staff interviews confirmed the expectation for immediate notification, but documentation and actions showed a delay.
A resident's dignity was compromised when staff failed to timely empty urine from her external catheter canister, leading her to sometimes empty it herself due to embarrassment. Despite facility policy requiring catheter care during the night shift, staff interviews revealed inconsistencies in following this procedure. The resident's representative had filed a grievance requesting the canister be emptied every morning, underscoring the facility's failure to maintain the resident's dignity.
A resident reported excessive wait times for call light responses, ranging from 30 to 50 minutes, with a specific instance of a 48-minute wait. Despite complaints, the facility did not provide a resident handbook or explain the grievance process, and the DON's limited investigation found no issues. The facility failed to assess the root causes of the delays or interview residents, leading to unresolved grievances.
A resident did not receive timely medical appointments with specialists as ordered by the physician, including a dermatologist, urologist, and infectious disease specialist. Despite orders being documented, the facility failed to arrange these appointments, leading the resident's family to intervene. The DON acknowledged the oversight and was working on scheduling the appointments.
Physical restraint used during resident care
Penalty
Summary
The facility failed to ensure a resident was free from physical restraint when a CNA placed one hand over the resident’s mouth and the other hand over the resident’s arms during incontinence care. The resident had diagnoses of Alzheimer’s disease and dementia with behavioral disturbance, a history of behavioral symptoms, and severe cognitive impairment with a BIMS score of 4 out of 15. The resident also required substantial to maximal assistance with toileting hygiene and bathing. According to the facility investigation and staff statements, the resident was yelling and striking out during care when the CNA entered the room to assist another CNA. One CNA reported that the second CNA placed a hand over the resident’s mouth for about two minutes while the resident tried to move and strike out, then grabbed the resident’s hands, held them against the resident’s chest, and pushed the resident back onto the bed. Another CNA reported that the resident was combative and that the CNA held the resident’s hands so the resident would not hit her. The resident’s representative stated the resident would have been fearful if she could recall the incident and that covering her mouth would have been frightening. The resident’s care plan identified confusion, anxiety related to dementia, yelling, and hunger-related behaviors, but it did not include interventions for physically aggressive behavior during care. The resident’s record also documented ongoing behaviors such as yelling, rejection of care, and anxiety. The facility investigation concluded it could not substantiate or unsubstantiated abuse, but the record and interviews documented that the resident was physically restrained during care.
Insufficient Nursing Staff Led to Delayed Call Light Response and Missed Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs for timely assistance with showers and call lights. The staffing policy stated the facility maintains adequate staff on each shift to meet residents’ needs and uses the facility assessment to determine staffing levels. The facility assessment listed an average daily census of 116 residents, a bed capacity of 187 residents, and desired daily staffing of 15 nurses and 28 CNAs, but the schedule review showed multiple dates when staffing fell below those levels for nurses and CNAs. Residents described repeated delays in care and services. One resident said staffing, especially on nights, was an issue and reported waiting over an hour for a call light to be answered and sometimes receiving no shower for a week or more. Other residents reported waiting over an hour to use the restroom, missing timely assistance with transfers, and being unable to get to bed until late because staff were occupied with other residents. Several residents stated that showers were not provided as scheduled, that they sometimes had to initiate the shower themselves, and that call light response times often depended on staffing levels. Observations confirmed delayed response to call lights. During one continuous observation, a resident’s call light was not answered for 25 minutes while staff walked past the room or did not stop to check on the resident. During another observation, a resident who needed help getting out of bed waited while a CNA said she was waiting on a nurse to assist; after repeated returns to the room, the CNA ultimately told the resident she would have to complete care in bed because another staff member could not be obtained. Grievances from the prior months also documented call light delays of up to several hours and showers being cancelled or not completed because of staffing concerns. Staff interviews acknowledged that the facility often needed more help on all shifts, that call-offs affected coverage, and that some showers could not be completed because there was not enough staff.
Food Served Cold, Bland, and Inconsistently Prepared
Penalty
Summary
The facility failed to ensure residents consistently received food that was palatable in taste, texture, and temperature. The facility policy stated that food should be prepared by methods that conserve nutritive value, flavor, and appearance, and that food and drink should be palatable, attractive, and served at a safe and appetizing temperature. During a group interview, residents reported that the kitchen frequently ran out of items such as ice cream and Greek yogurt, that substitute items were usually offered, and that the quality of food was inconsistent. They also said over-easy eggs were often overcooked, scorched, and hard, and that only one frying pan was available for preparing fried eggs in the upstairs dining room. Multiple residents described meals that were cold, dry, hard, missing items, or otherwise unappetizing. One resident said scrambled eggs were cold and breakfast was not served in a timely manner despite a sign requesting not to be awakened before 7:30 a.m. Another resident said food was sometimes served cold, while another reported pancakes were hard and dry, hamburgers were cold, and milk was often missing with cereal. Additional residents reported repetitive menus, cold food, forgotten trays, incorrect meal items, and lunches that did not arrive. One resident said she received coffee without creamer, oatmeal was not provided, and cereal was served without milk because staff said there was no milk that day. Surveyors also observed a regular diet test tray after lunch service and found the spinach lacked flavor, the mashed potatoes had a pasty consistency and bland taste, the meatloaf was bland, and the cornbread was doughy and bland. Record review showed a prior concern about cold food, including a dietary audit documenting trays sitting for 30 minutes before the last tray was delivered and stew temperature dropping from 175 degrees F to 130 degrees F. Staff interviews indicated food temperatures were monitored and meals could be remade if residents complained, but residents continued to report cold and unappetizing food, and one resident described a pot pie that did not resemble a pot pie and appeared as broken pieces of chicken and vegetables.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Medications and biologicals were not consistently labeled or stored according to accepted professional principles in three medication carts and two medication storage rooms. During observation of the second floor west medication cart, an opened bottle of sublingual nitroglycerine had no resident name on it, a used Wixela inhaler for a resident was not labeled with the date it was opened, and an opened bottle of docusate sodium remained in use past its expiration date. In the second floor west medication storage room, an opened bottle of tuberculin purified protein was also found without an open date. Additional medication storage problems were observed in other areas. In the third floor east medication cart, a box of 5% lidocaine patches remained with medications for a resident who had already been discharged. In the first floor east medication cart, three opened insulin glargine pens for three residents were undated, a half-used bottle of normal saline was labeled only with an open date, an opened water bottle had a staff member's name written on it, and an opened bottle of chocolate syrup was partially full and stored in the cart despite instructions to refrigerate after opening. In the first floor medication storage room, an unopened RSV test remained with an expired physician order, and an opened tuberculin purified protein vial was present with an expiration date. During interviews, nursing staff acknowledged several of these issues. An RN stated the nitroglycerine bottle should have been labeled with the resident's name, thought the inhaler could be used until empty, and did not know how long the tuberculin vial was good after opening. An LPN stated the discharged resident's lidocaine patches should have been removed from the cart after discharge and said insulin pens must be used within 30 days of opening. The DON later stated that nitroglycerin vials were for individual resident use and should be labeled with the resident's name, that insulin pens, Wixela inhalers, and tuberculin vials should be labeled with the open date and discarded according to manufacturer instructions, and that medications for a discharged resident should be removed from the cart within 24 hours.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse in multiple incidents involving resident-to-resident contact. The report states that three residents were affected: one resident was physically abused by another resident, and two residents were sexually abused by the same resident. The facility’s own investigation and record review documented that these events occurred and that the residents involved had significant cognitive or behavioral impairments. Resident #31, who was cognitively intact with a BIMS score of 14 out of 15, was involved in an incident with Resident #39, who had dementia, severe impairment in daily decision-making, and a history of physical and verbal behaviors toward others. Staff reported that Resident #39 was in Resident #31’s room or doorway, grabbed her leg, and asked for help. Resident #31 stated that when she bent down to help him, he hit her chest, causing pain. The investigation documented that Resident #39 was removed from the area and later placed on one-to-one supervision. Resident #31’s care plan was not updated after the incident to reflect her tendency to help others even when they might not want help. Resident #71, who had severe cognitive impairment with a BIMS score of 2 out of 15 and required partial to moderate assistance with all ADLs, was sexually abused by Resident #149. Staff observed Resident #149 sitting next to Resident #71 while she was asleep on a couch in the common area and placing his hand down inside her pants. Resident #71 slept through the occurrence and later did not remember the incident because of cognitive impairment. The investigation documented that Resident #149 had a history of grabbing others, public indecency, inappropriate sexual comments to women, and repeated entry into female residents’ rooms before the incident occurred. Resident #96, who had dementia, encephalopathy, morbid obesity, acute respiratory failure, and a BIMS score of 4 out of 15, was also sexually abused by Resident #149. Staff witnessed Resident #149 reach down and touch Resident #96’s breast over her clothing while she was sitting in a wheelchair near the nurses’ station. The report documents that Resident #149 had a known pattern of hypersexual and inappropriate behavior toward women, including prior sexual comments and masturbation in common areas. The facility investigation substantiated the abuse involving Resident #96 and documented that the resident was cognitively impaired and did not recall the incident.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an alleged physical abuse incident involving a resident to the State Survey and Certification Agency in accordance with state law. The resident involved was cognitively intact, with diagnoses including multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale, malnutrition, hyperlipidemia, and hyperthyroidism. The resident stated that a male resident entered her room, she tried to help him, and he hit her in the chest, causing pain. Record review showed that staff were notified after a CNA found the male resident inside the resident’s room and the resident reported that he had hit her chest. Another CNA reported seeing the male resident in front of the room, grabbing the resident’s leg while asking for help finding his buddy, and staff removed him from the room. A skin and pain assessment were completed, the resident said the area where she had been hit was sore, and one-to-one supervision was provided for the male resident. The facility’s investigation documented that the interdisciplinary team did not feel the incident was reportable because they did not feel there was an allegation or intent. During interviews, staff gave differing descriptions of the event, including that the resident reported being punched in the chest and was holding her chest when she described the incident. The social services assistant, unit manager, DON, and NHA all discussed the event and the facility’s response. The NHA stated the facility was uncertain about reporting because of the resident’s interview, but later acknowledged that the male resident had willfully hit the resident and that the incident should have been reported to the State Survey Agency.
Missed Scheduled Showers for Two Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary assistance to maintain personal hygiene, specifically by not providing scheduled showers for two residents. The facility policy stated residents would receive assistance as needed with ADLs and that residents unable to carry out ADLs would receive services to maintain good grooming and personal hygiene. Surveyors reviewed bathing records, care plans, progress notes, and interviewed the residents and staff. One resident, admitted with a right ankle fracture, muscle weakness, and a history of falls, was cognitively intact and required partial to moderate assistance with bathing and showering. She reported that the shower schedule was inconsistent, that she had to seek staff out to request showers, and that she did not receive showers on scheduled days. Records showed a preference for Wednesday and Saturday evening showers, but documentation did not show showers on two scheduled March dates, and there was no documentation explaining why the showers were missed or showing refusals. Staff interviews indicated showers were expected to be completed for dependent residents and that missed showers should be documented and communicated, but no such documentation was found for this resident. A second resident, admitted with a left humerus fracture, heart disease, UTI, and diabetes, had moderate cognitive impairment and required substantial assistance with hygiene and bathing. During interview, the resident’s hair was disheveled and she stated she had not been getting showers as scheduled and had not had one in at least a week. Her care plan and bathing preference indicated twice-weekly showers, but the shower record showed a nine-day gap between documented showers, with no documentation of refusals. The DON stated the resident should have received two showers per week and could not explain the gap or the discrepancy in the shower record.
Failure to Enter and Follow Post-Orthopedic Dressing Orders
Penalty
Summary
The facility failed to ensure Resident #46 received treatment and care in accordance with physician orders after an orthopedic follow-up appointment. Resident #46 was admitted with a displaced trimalleolar fracture of the right lower leg, muscle weakness, and a history of falling. The resident was cognitively intact and required assistance with several activities of daily living. After the orthopedic visit, the cast and sutures were removed, and the orthopedic note stated the resident could shower over the incision but not submerge it under water, with dressing changes to be completed daily or every other day. The resident reported that the dressing on the right ankle was not changed until the morning of 3/9/26 after she brought it to staff attention. Review of the medical record showed no physician orders for the dressing changes were entered after the 3/4/26 orthopedic appointment, and there was no documentation that the ankle dressing had been changed as ordered. A wound care order for cleansing and application of a dry dressing with ACE wrap every other day was not initiated until 3/11/26 at 2:25 p.m., during the survey.
Inaccurate transfer status and delayed therapy review after bruising during transfer
Penalty
Summary
The facility failed to ensure Resident #33 received adequate supervision during transfers and failed to keep her transfer status accurate and current in staff-directed records. Resident #33 was over age 65, admitted with Parkinson’s disease, chronic respiratory failure, myocardial infarction, and atrial fibrillation, and her MDS showed she was cognitively intact, required substantial to maximal assistance with ADLs, was dependent on staff for transfers, and was taking an anticoagulant. Her care plan, revised on 1/13/26, directed maximum assistance of two people using a Sara Steady, while the Kardex dated 3/10/26 identified her as a two-person maximum assist with a Hoyer lift. Staff interviews showed confusion about whether she required a Sara Steady or a Hoyer lift, and CNA #6 stated the Kardex should reflect the resident’s transfer needs. Resident #33 reported that staff used a sit-to-stand lift incorrectly during a transfer and that the sling/belt was not placed correctly. She stated the transfer caused pain, and she yelled for the CNA to stop, but the CNA continued lifting her from the wheelchair. The resident later had a large bruise on her back and bruising on her side and breast area. Nursing documentation noted bruising across her back and left side, and one nurse changed her transfers from a Sara Steady to a Hoyer lift with instructions to pad under her shirt with pillows during Hoyer transfers. Staff interviews also reflected that the resident had bruising related to a sling and that the incident may have involved improper lift use. The record also showed that therapy was not timely involved after the bruising and transfer concern. Social services documented that the SSD would review transfer concerns with the therapy team, but the EMR did not show documentation that therapy was notified to review the resident’s transfer concerns. The director of rehabilitation stated the resident had not been on the therapy caseload since 2/4/26, before the bruising occurred, and that staff had concerns about the resident’s transfer status. Interviews with nursing and therapy staff showed differing views about whether therapy had assessed the resident for the appropriate lift and whether the resident should have been using a sit-to-stand or a Hoyer lift.
Delayed Pain Medication Administration
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. Resident #147 was admitted after explantation of a knee joint prosthesis and infection/inflammatory reaction involving the left knee prosthesis, with diagnoses including seizure disorder and neuropathy. The resident had severe left knee pain documented on the MDS note, and the pain care plan initiated on 3/5/26 identified that the resident expressed pain and included evaluation of pain interventions and administration of pain medication as ordered. The March 2026 physician orders included numeric pain assessments every four hours for three days and hydromorphone HCL 2 mg by mouth every four hours as needed for pain. The resident stated that after arriving at the facility, pain increased to 8/10 at 10:00 p.m. and later to 10/10 at 5:00 a.m., but the first dose of hydromorphone was not administered until 11:30 a.m. the next day. The record showed hydromorphone was not given until 19.5 hours after the resident began rating pain at a 7 level, and Tylenol was not documented until later, with no physician orders for Tylenol documented until 3/10/26. The DON stated the resident should have had pain medication available on admission, that the automated medication dispensing system contained the ordered hydromorphone, and that the nurse should have administered it when requested.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three of five CNAs, specifically CNA #2, CNA #15, and CNA #16, and therefore did not determine potential training needs for those staff members. The facility’s Performance Evaluation policy stated that annual performance reviews are given to all associates, and that ongoing performance feedback is encouraged throughout employment. Record review showed CNA #2’s last employee evaluation was on 7/14/23, CNA #15’s last employee evaluation was on 6/5/24, and CNA #16’s last employee evaluation was on 7/14/23. During interviews, the DON stated that the staffing development coordinator tracked employee evaluations, and the NHA stated that all-staff training was done during the annual skills fair; the NHA also stated the SDC could not be interviewed because the SDC was in the hospital.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with surveyors identifying a 10.34% error rate based on 3 errors out of 29 opportunities for error. During observation of medication administration, an RN prepared oxycodone for a resident with an order for 5 mg every 3 hours for pain, placed the tablet in a cup on the bedside table, left the room, and later asked the resident if she had taken the medication rather than directly observing ingestion. The resident did not have an order or assessment allowing unsupervised self-administration. Surveyors also observed an LPN preparing medications for another resident with an order for Seroquel 37.5 mg twice daily for dementia with behaviors. The LPN incorrectly identified propranolol as Seroquel, placed the propranolol into the medication cup, and documented the Seroquel as given on the MAR. In a separate observation, the same LPN correctly identified Seroquel but administered only 25 mg instead of the ordered 37.5 mg dose. Interviews confirmed the incorrect medication selection, the incorrect dose, and that the resident could have received an additional dose later because the Seroquel had been charted as administered.
Wrong Medication Prepared and Documented for a Resident
Penalty
Summary
The facility failed to ensure Resident #34 was free from a significant medication error when the wrong medication was prepared for administration. Resident #34 had diagnoses including Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder, and the resident's MDS showed severe cognitive impairment with a BIMS score of 4 out of 15. The physician's orders included Seroquel 37.5 mg twice daily for dementia with behaviors and propranolol HCL 20 mg, one tablet by mouth twice daily, with instructions to hold for heart rate less than 55 beats per minute. During medication preparation, an LPN removed a medication from the cart labeled propranolol 20 mg, stated it was Seroquel, placed the propranolol tablet into the medication cup, and documented Seroquel as given on the MAR. The medication cup containing propranolol was taken to the resident, but the dose was not administered because the error was identified before administration. The LPN stated the resident was not due for propranolol until later that evening and acknowledged that documenting Seroquel as given would have meant the resident could have received propranolol twice within a few hours. The DON stated the resident could have had an adverse reaction from receiving propranolol instead of the prescribed medication.
Missing hospice care plan for a resident admitted to hospice
Penalty
Summary
The facility failed to ensure hospice services met professional standards and principles for one resident who was receiving hospice care. Resident #62, who had diagnoses including senile degeneration of the brain, Alzheimer's disease, and dementia with psychotic disturbance, had severe cognitive impairment with a BIMS score of 3 and needed supervision or touching assistance with most activities of daily living. The resident was admitted to hospice with a diagnosis of senile degeneration of the brain, and the MDS indicated she was receiving hospice care. Record review showed the resident's comprehensive care plan, reviewed after hospice admission, did not include a hospice care plan with a delineation of care. Staff interviews reflected confusion about who was responsible for creating the hospice care plan: one LPN said there was no hospice communication book and everything was uploaded into the EMR, the SSA said he was not responsible for creating the hospice care plan and thought nursing or the unit manager was responsible, and another LPN said she did not initiate hospice care plans and that the MDS nurse did. The DON stated hospice care plans should be initiated at the time of hospice admission and should include a delineation of care, and acknowledged that Resident #62 did not have a hospice care plan.
Survey Results Binder Missing Required Findings
Penalty
Summary
The facility failed to ensure residents, family members, and legal representatives had full access to review the results of the most recent survey findings, including survey results, certifications, complaint investigations, and plans of correction in effect for the past three years. On observation, the survey results binder in the front lobby contained findings from surveys dated 9/28/22, 11/12/20, and 9/26/19, but it did not include the facility’s most recent recertification survey from 1/23/24 or the last three years of complaint findings. During interview, the NHA stated that the most recent survey and the last three years of complaint findings should have been in the binder and said she had thought they were already there.
Failure to Notify Resident's Representative After Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's designated representative of a significant change in the resident's condition, specifically following a fall. According to the facility's policy, staff are required to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there is an accident or significant change in status. In this case, the resident, who had a history of falls and multiple medical conditions including stroke, acute respiratory failure, and osteoarthritis, experienced a fall during the night. The nurse's progress note documented the fall, the resident's condition, and that the physician was notified, but there was no documentation that the resident's representative was informed at that time. The resident's representative later reported not being notified of the fall until the resident was transferred to the hospital after becoming unresponsive, approximately eight hours after the incident. The representative expressed frustration and distress over not being informed promptly, especially as she was the resident's power of attorney and had previously communicated her expectation to be notified at any time, including during the night. Hospital records indicated the resident had a large subdural hematoma and was placed on hospice care, passing away four days later. Interviews with staff, including LPNs, RNs, and the DON, confirmed that the facility's protocol was to notify the resident's representative immediately after a fall, regardless of the time, unless otherwise care planned. However, in this instance, the notification was delayed until after the resident's condition had significantly deteriorated and he was transferred to the hospital. The DON acknowledged the delay and lack of awareness regarding the representative's wishes for immediate notification.
Failure to Maintain Resident Dignity in Catheter Care
Penalty
Summary
The facility failed to maintain the dignity of a resident by not emptying urine from her external catheter canister in a timely manner. The resident, who was cognitively intact and required assistance with transfers and bed mobility, reported that staff did not consistently empty the urine canister in the morning, leading her to sometimes empty it herself due to embarrassment. Observations confirmed that the canister was partially filled and visible in the resident's room, and the resident's representative corroborated that the canister often contained urine during visits. The facility's policy required catheter care during the night shift and specified that the canister should be emptied when it was three-quarters full. However, interviews with staff revealed inconsistencies in following this policy. A registered nurse claimed that the canister was emptied every morning, while the director of nursing was unsure of the frequency and acknowledged that the canister should be emptied before reaching a certain capacity. A grievance had been filed by the resident's representative, requesting that the canister be emptied and rinsed every morning, highlighting the facility's failure to adhere to its own procedures and maintain the resident's dignity.
Failure to Address Long Call Light Wait Times
Penalty
Summary
The facility failed to promptly address grievances related to resident care, specifically concerning long call light wait times. Resident #1, who was cognitively intact and required significant assistance due to conditions such as cellulitis and post-polio syndrome, reported waiting 30 to 50 minutes for call light responses. The resident's representative also noted a 48-minute wait for assistance during a visit. Despite these complaints, the facility did not provide a resident handbook or explain the grievance process to Resident #1, hindering their ability to formally address these issues. The facility's response to the grievances was inadequate, as evidenced by the director of nursing's (DON) interview. The DON acknowledged reviewing complaints from a resident council meeting but found no concerns after speaking with staff and conducting limited observations. The facility did not conduct a comprehensive assessment to identify the root causes of the long wait times, nor did they interview residents to gauge the extent of the issue. This lack of a systematic approach to addressing grievances contributed to the ongoing problem of delayed call light responses.
Failure to Arrange Timely Medical Appointments
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident. The resident, who was cognitively intact and required assistance with transfers and bed mobility, had been waiting for medical appointments with a dermatologist and a urologist as ordered by the physician. Additionally, there was a delay in arranging an appointment with an infectious disease specialist for the resident's chronic cellulitis. Despite the physician's orders for these referrals being documented in May 2024, there was no evidence in the electronic medical record that the appointments had been made. Interviews with the resident and their representatives revealed that the family had to intervene by contacting the primary physician to request a referral for the infectious disease specialist, as the facility had not taken action. The Director of Nursing (DON) stated that the unit managers were responsible for processing referrals and scheduling appointments, but the unit manager was unaware of the referrals for this resident. The DON acknowledged that the appointments should have been made by this time and was working on scheduling them on the day of the interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 233 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Longmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peaks Care Center, The | 1.4 mi | ★★★★★ | 13 | 0 |
| Mcintosh Care And Rehabilitation Center | 1.5 mi | ★★★★★ | 10 | 0 |
| Katherine And Charles Hover Green Houses | 1.7 mi | ★★★★★ | 9 | 0 |
| Accel At Longmont Health And Rehab, Llc | 4.9 mi | ★★★★★ | 47 | 1 |
| Berthoud Care And Rehabilitation | 7.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.