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 Mcintosh Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with stroke history, AFib, and Eliquis use was transported in a van for a swallow study when her wheelchair was not fully secured. During the trip, the wheelchair shifted and her head struck the van interior, resulting in an ED transfer and a CT-confirmed subdural hematoma with ICU monitoring.
Failure to Honor Resident Shower Preferences: Multiple residents with documented bathing preferences did not receive showers consistently according to their care plans and POC records. One resident with dementia repeatedly refused showers, while other residents with MS, morbid obesity, and vascular dementia reported or were documented as missing showers and bed baths despite stated preferences. Records showed missed bathing opportunities, inconsistent documentation of refusals, and no clear evidence that alternate times or bed baths were consistently offered when showers were not completed.
A facility failed to maintain a clean, comfortable, and homelike environment when multiple resident rooms lacked clean hand towels and washcloths on repeated observations. Residents reported having to ask for linens, often not receiving them, and sometimes using paper towels or dirty towels instead. Staff said clean towels and washcloths should be provided daily, but the linen closet was observed with limited supply and rooms remained without linens.
Loose medications were found at the bottom of a medication cart drawer, including fluoxetine, losartan, methocarbamol, potassium chloride, and a multivitamin. An LPN said a loose pill could be mistaken for the wrong medication and lead to a medication error, and the DON stated that nurses were responsible for keeping the cart clean during the shift and retrieving any pill that popped into the drawer.
Meal choices were not consistently honored after the resident aide role ended. Residents reported they were not regularly given menus or asked for orders, and several said they kept receiving foods they had already identified as dislikes or allergies, including pork, milk, pasta, salad, and red sauce items. Observations confirmed meals were served that did not match the meal tickets, and resident council feedback showed ongoing concerns about inconsistent meal ordering.
Environmental Deficiencies in Laundry and Soiled Utility Areas: Surveyors observed the laundry area and three soiled utility rooms with missing and cracked floor tiles, torn and peeling sheetrock, dust buildup, debris, chipped paint, a hole in the wall, a loose heater cover, and missing wall tiles. The housekeeping supervisor said no work orders had been placed before the survey, and the maintenance supervisor acknowledged the issues and said the flooring was ordered to be replaced.
A resident with MS, GERD, bipolar disorder, muscle weakness, and chronic pain had a MOST form indicating no CPR, but the CPO and care plan still listed CPR. Surveyors also observed a green dot by the room door indicating full code, and the DON confirmed the resident had stated a wish for no CPR.
Dishwashing Room Not Maintained in Good Repair: Surveyors found the facility’s dishwashing room was not maintained in accordance with food service safety standards. Observations included chipped paint, debris and lint on vent covers, a partially unpainted wall, dusty ceiling pipes, torn floor laminate, a separated baseboard, and dirt and debris on the floor. The NHA said he was not aware of the issues, and the RD said she had not submitted any work orders.
A resident reported that a CNA was rough and impatient during incontinence care, making her feel terrible and helpless. Despite a behavior care plan addressing potential mood issues, the resident's concerns about the CNA's treatment were not adequately addressed. The facility's investigation found the neglect allegation unsubstantiated, but the resident's report of rough treatment remained a significant concern.
Unsafe wheelchair transport led to resident head injury
Penalty
Summary
The facility failed to ensure safe transportation and adequate supervision for one resident who was being transported in the facility van for a swallow study. The resident had a history of cerebral infarction (stroke), acute respiratory failure, atrial fibrillation, pacemaker, osteoarthritis, obesity, hypertension, and acute kidney failure, and was receiving Eliquis for atrial fibrillation and a recent stroke. The resident’s MDS indicated no cognitive impairment with a BIMS score of 14 out of 15 and set-up assistance needed with transfers. During transport, the resident’s wheelchair was not properly secured in the van. The facility investigation documented that the resident was assisted into the transportation bus and, while en route, the wheelchair shifted and the resident’s head made contact with the interior of the van. The driver reported that he secured the resident in the wheelchair, locked the brakes, and secured the back of the wheelchair and the seatbelt and shoulder strap, but did not place the front straps on the wheelchair even though he knew that was part of the procedure. He later stated that after hearing a noise and the resident scream, he found her still in the wheelchair and reported that she said she hit the back of her head on the window. The resident was taken to the ED and hospital records documented a traumatic subdural hematoma, with a CT scan showing a 3 mm bleed. Because the resident was on Eliquis, she was admitted to the ICU for monitoring and started on Keppra for seizure prophylaxis. The facility investigation and staff interviews confirmed the incident occurred during transportation when the wheelchair was not fully secured, and the DON and NHA stated the resident initially declined the ER and insisted on going to the swallow study appointment before later being transferred for evaluation.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor resident choice and self-determination by not consistently providing showers according to residents’ preferences and care plans for four residents. The deficiency involved Resident #17, Resident #29, Resident #41, and Resident #77, all of whom had documented bathing preferences in their care plans and point-of-care (POC) records. The facility policy stated residents would be provided showers as requested or according to the facility schedule and based on resident safety. Resident #17, who had unspecified dementia and a BIMS score of 8, preferred showers in her room on Monday and Thursday evenings. Her POC bathing documentation from 2/19/26 through 3/16/26 showed she refused all showers, with reasons such as being too cold, not wanting one, having a full schedule, hot water being out, or it being too late. The record did not show that she received showers or bed baths on other days, and there was no documentation that staff tried different times or other interventions. Resident #29, who had MS, weakness, and a BIMS score of 15, said she was not receiving showers as often as she should and stated she was not regularly asked. She reported that she developed scabs on her scalp if she did not use her shampoo regularly and said she would not refuse showers. Her care plan and POC showed a preference for showers on Monday, Wednesday, and Friday evenings, but records documented only four showers out of nine opportunities. One POC entry showed a shower was provided on 3/4/26, while a CNA shower/bath form for that same day documented refusal. Resident #41, who had morbid obesity and was cognitively intact with a BIMS score of 15, preferred showers twice weekly. She told the surveyor she did not receive showers and was not offered bed baths when she did not feel well enough to get out of bed, and that not showering made her feel forgotten and disgusting. Her POC showed a preference for Wednesday and Sunday evening showers, but she received only one shower out of seven opportunities. A progress note documented she switched her shower to the next day, but there was no documentation that a shower or bed bath was offered or provided that day. Resident #77, who had vascular dementia, need for assistance with personal care, and a BIMS score of 4, had a care plan stating she preferred showers on Tuesdays and Thursdays and a bed bath on Saturday evenings, while the POC listed Tuesday and Friday day-shift showers. Records showed she received one shower out of nine opportunities and missed four bed bath opportunities, for a total of 13 missed bathing opportunities. CNA shower/bath forms documented refusals on multiple dates, including entries with no reason documented and one form lacking a nurse signature. Staff interviews indicated CNAs were responsible for showers, residents who refused should be re-approached multiple times, nurses should be notified, and bed baths should be offered, but the records for these residents did not show consistent bathing according to their stated preferences.
Missing Clean Towels and Washcloths in Resident Rooms
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for resident rooms on two of four units because clean linen hand towels and washcloths were not available in resident rooms on a daily basis. During an initial tour, resident rooms 306, 318, 406, 407, 410, and 412 did not have linen towels or washcloths in the rooms, and the same rooms were again observed without linen towels or washcloths on a subsequent tour the next day. The facility had one linen closet used for all units, and when it was observed, it contained only two hand towels, 20 washcloths, and 30 white bath towels. Resident interviews confirmed that clean towels and washcloths were often not available. One resident said she rarely had linen towels or washcloths and would be more likely to wash herself up if they were available. Another resident said she had to ask for clean towels and washcloths and most times did not receive them, which was frustrating. Other residents reported using paper towels because dirty towels were not picked up and replaced, or said they were not offered linen washcloths or towels in the evening to wash their face or hands. Staff interviews indicated that towels and washcloths should be passed out daily, that all shifts were responsible for providing them, and that dirty linen should be removed and replaced daily and as needed.
Loose Medications Found in Medication Cart Drawer
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for one of the two medication carts. During observation of the 300 north medication cart with an LPN, surveyors found 40 loose medications at the bottom of the medication cart drawer. The loose medications included fluoxetine, losartan, methocarbamol, potassium chloride, and a multivitamin, and the LPN was able to identify some of the pills in the drawer. The facility’s Medication Storage policy stated that medication carts should be kept clean and organized and that dropped, loose, refused, or unused medications should not be placed in the trash, red biohazard/sharps containers, or taped back into prescription cards. In interview, the LPN stated that a loose medication could be picked up and mistaken for the wrong medication, which could result in a medication error. The DON stated that the nurse assigned to the medication cart was responsible for cleaning it during the shift and that if a pill popped out into the drawer, it should be retrieved.
Meal Choices Not Consistently Honored
Penalty
Summary
The facility failed to ensure meals were served according to resident preferences on three of four units because residents were not consistently provided menus or given the opportunity to choose their meals. The facility policy stated that food preferences, allergies, intolerances, and cultural, ethnic, and religious requests should be noted and honored, and that nursing staff or designees were responsible for obtaining meal orders and documenting them on tray tickets. During observation of the service line, residents were served meals that did not match the dislikes listed on their meal tickets, including pasta served to a resident who disliked pasta, salad served to a resident who disliked salad, and pasta in red sauce served to a resident who disliked lasagna, marinara, and rose sauce. Resident interviews showed that several residents were not receiving consistent meal choice opportunities after the resident assistant position was eliminated. One resident said she never knew what she was going to receive and that staff did not consistently come around to take orders. Another resident reported that dislikes and allergies such as pork, fish, and thyme continued to be served because she was given the regular menu and that pork items were frequently placed on her breakfast tray despite telling CNAs she did not like pork. A third resident said CNAs did not come around daily to take orders and that she often received the main menu item even when it contained foods she would not choose. Another resident said she did not eat a lunch of pasta with red sauce because it looked too much like lasagna, which she had told staff she did not like. A resident group interview reflected the same pattern. Residents stated that meal order taking had not been consistent since the resident assistant position ended, that they did not always know what they would be served, and that some had to obtain menus themselves from the nurses' station to fill out. One resident reported being served sandwiches repeatedly because of allergies and feeling stuck with those choices, while another said he continued to receive milk every morning even after telling CNAs he did not drink milk. Record review showed resident council and food council concerns about meal tickets and meal choice, and a dietary performance improvement plan identified that meal orders were not being taken regularly. Staff interviews confirmed that CNAs were expected to take over meal order duties after the resident aide position ended, but the regional dietary resource acknowledged the facility was still in transition and that staff should provide meal descriptions, ask about alternatives, and communicate dislikes to dietary staff.
Environmental Deficiencies in Laundry and Soiled Utility Areas
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public because the laundry area and three soiled utility rooms had multiple environmental concerns. On 3/17/26, surveyors observed the soiled utility room in the laundry area with multiple layers of floor linoleum tile cut out and eight tiles missing, dirt and debris along the base tiles behind the entrance door, torn sheetrock along the walls, areas of torn sheetrock without texture or paint, dust built up behind the dryer near the vent pipe, peeling sheetrock outside the dirty utility room, missing cover-base tiles for approximately three feet, torn linoleum near the stand-alone washer, a three-by-three-inch hole in the wall by the washer, chipped paint outside the dirty utility room, and a missing transition strip with five chipped floor tiles. On 3/19/26, the same concerns remained except the hole had been repaired. Surveyors also observed additional damage in the north and south soiled utility rooms. The north soiled utility room had sheetrock damage above the hopper and three cracked floor tiles under the hopper and four cracked floor tiles under the bins. The south soiled utility room had a loose metal heater cover and nine missing wall tiles at the door. The housekeeping supervisor said she had not placed any work orders to have anything corrected before the survey and stated it was the responsibility of staff to place work orders for items to be fixed or replaced. The maintenance supervisor said the flooring was ordered to be replaced, would start in the more visible areas, and acknowledged that the issues were a problem and a safety concern if a staff member tripped and fell.
Advance Directive Records Did Not Match Code Status
Penalty
Summary
The facility failed to maintain accurate medical records for advance directives for one resident. Resident #29, who was admitted with diagnoses including multiple sclerosis, GERD, bipolar disorder, muscle weakness, and chronic pain, had a BIMS score of 15 out of 15 and was cognitively intact. The resident's MOST form, signed by the resident and the NP, indicated no CPR with selective treatment, including IV antibiotics and fluids, do not intubate, and avoid intensive care. However, the computerized physician order showed the resident's code status as CPR, and the care plan review document also listed the resident's advance directive as CPR. Surveyor observations and interviews showed the inconsistency remained in multiple locations. A green dot was observed next to the resident's door name tag, which staff identified as indicating full code status. The DON stated the advance directive forms should match the CPO and that when a resident's advance directive changed, the nurse receiving the new order was expected to discontinue the old order and initiate the new order in the CPO. The DON also confirmed the resident had told her she wanted no CPR, and said the order was changed in the EMR.
Dishwashing Room Not Maintained in Good Repair
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety because its one dishwashing room was not maintained and repaired in a timely manner. During the environmental tour, surveyors observed chipped paint on the wall at the entrance to the room, an air vent exterior metal cover with black debris and lint, one wall that was not completely painted, and an exhaust vent over the dishwashing machine with areas of black debris. The ceiling pipes were dusty, and there was torn floor laminate approximately four feet long at the juncture of the floor and wall under the sink near the dishwashing machine. Surveyors also observed the baseboard separated from the wall almost the entire length of the wall under the sink, and the left corner of the room at the entrance door was dirty with debris scattered on the floor. During the environmental review with the surveyor, the NHA observed these concerns and stated he was not aware of them. The RD also observed the concerns and stated she had not put in any work orders for them. The facility policy stated housekeeping and maintenance services were to be provided as necessary to maintain a sanitary, orderly, and comfortable environment, and staff were to report unresolved environmental concerns to the NHA.
Resident Care Lacked Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident's care was provided in a dignified and respectful manner by a certified nurse aide (CNA). The resident, who was over 65 years old and had diagnoses including epilepsy, bipolar disorder, low back pain, and muscle weakness, was cognitively intact and required assistance with various activities of daily living. During an interview, the resident reported that the CNA was rough during incontinence care, hurried her through tasks, and was impatient due to the resident's inability to move quickly because of her wheelchair use. The resident expressed feeling terrible and helpless due to the CNA's treatment, which she described as rude. The facility's records indicated that a behavior care plan was in place for the resident, addressing potential mood and behavior problems related to her bipolar disorder. However, the care plan did not specifically address the resident's concerns about the CNA's rough handling. The facility's investigation into the incident revealed that the resident had previously reported feeling safe and having no issues with the CNAs, including the one in question. Despite this, the resident later reiterated her concerns about the CNA's rough and rude behavior. Interviews with staff, including the CNA involved, revealed differing perspectives on the incident. The CNA claimed that the resident was not following orders and was in a mood on the day of the concern. The Director of Nursing (DON) and other staff members were informed of the resident's complaint, and the CNA was temporarily reassigned. The facility's investigation found the allegation of neglect to be unsubstantiated, but the resident's report of rough treatment by the CNA was a significant concern that was not adequately addressed in the care plan or during the initial investigation.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Katherine And Charles Hover Green Houses | 0.5 mi | ★★★★★ | 9 | 0 |
| Peaks Care Center, The | 1.1 mi | ★★★★★ | 13 | 0 |
| Life Care Center Of Longmont | 1.5 mi | ★★★★★ | 16 | 0 |
| Accel At Longmont Health And Rehab, Llc | 3.4 mi | ★★★★★ | 47 | 1 |
| Berthoud Care And Rehabilitation | 8.9 mi | ★★★★★ | 0 | 0 |
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