Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Sundance Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Failure to provide clean hand towels and washcloths: Observations found multiple resident rooms and bathrooms without cloth linens, with only paper towels available in some bathrooms and no towel racks in closets or bathrooms. Residents said they had to ask for towels, staff said towels were locked in linen closets and not passed out routinely, and the DON’s statement that towels were replaced daily was not supported by observations or resident interviews.
A resident with COPD and diabetes was identified as an independent smoker, but after staff found him in a basement area and believed he had been smoking, the record did not show a new smoking safety screen was completed. Staff described ongoing smoking-related behaviors and use of a sitter, while the DON said no new assessment was needed because the resident was not seen actively smoking. Surveyors also found that the facility’s crash carts did not have medical grade power strips readily available, with commercial strips in two carts and none in one cart.
Improper labeling of medications in medication carts. Surveyors found multiple inhalers, eye drops, oral meds, and morphine stored in labeled medication boxes but not labeled on the individual containers with the resident’s name and/or the date opened. An LPN, RN, ADON, and DON all acknowledged that meds should be labeled inside the boxes because the containers could be separated or mixed up, which could lead to a medication error.
Food was served with poor taste, texture, and temperature, and residents repeatedly complained that meals were cold, bland, too salty, overcooked, or lacked condiments. During lunch observation, a resident said the spinach did not taste right and another said lunch was horrible. A test tray showed dry, salty turkey, plain-tasting rice, and spinach that did not appear creamy or match the menu. Staff interviews confirmed the cook did not follow the recipe for creamed spinach, and the NHA acknowledged resident concerns and that dietary recipes were not being followed.
Kitchen Maintenance and Sanitation Deficiencies: Surveyors observed burned marks, peeling and missing wallpaper, holes in the wall, chipped paint, stains, duct tape on the swamp cooler, and loose or damaged venting and tile in the kitchen and dishwasher room. Staff said repair needs were not logged, the dietary manager had not informed maintenance of requests, and the maintenance director stated the observed issues were not in the work order system.
A resident with quadriplegia and systemic lupus, who was cognitively intact, was transferred to the hospital after a physician found phimosis requiring medical intervention. After the transfer, the facility cleaned out the resident’s room, stored his belongings, and later disposed of many items without documented consent from the resident or his representative. The record lacked progress notes showing proper notification to pick up the items, and staff said the notice was verbal.
Resident council dietary concerns were redirected to a separate food committee, but residents said they had not been given the opportunity to attend that meeting for several months. Meeting minutes showed dietary issues were deferred from resident council, yet the facility could not document that the food committee met as scheduled, and staff confirmed the committee had not been consistently held.
Failure to provide individualized activity programming for two residents. One resident with dementia, anxiety, and hospice status had documented interests in music, animals, news, reading, and socializing, but was observed lying in bed without meaningful activity or companionship, and her activity record lacked details of the independent or group activities provided. Another resident with depression and chronic pain wanted community outings and fresh air, but could not attend bus trips because the facility bus wheelchair lift was broken, and her activity record showed no outings.
A resident with type 2 DM used an insulin pump and Dexcom CGM, but the EMR lacked physician orders for the pump, BG monitoring, and pump oversight. The resident said staff did not review her BG readings and she was repeatedly served regular meals instead of the carbohydrate-controlled diet listed on the hospital discharge record. Surveyors observed non-carb-controlled meals and found no documentation that the missing orders had been obtained before the issue was identified.
Failure to consistently reposition and offload heels for a resident with pressure injuries. A resident with dementia, immobility, and incontinence had a stage 3 sacral ulcer and a heel pressure injury, yet was observed lying on her back for extended periods without repositioning, without heel boots, and at times wet in her brief. The care plan called for heel offloading, protective boots in bed and in the chair, and frequent turning and repositioning, but staff observations and interviews showed these interventions were not consistently implemented.
The facility failed to provide respiratory care per physician orders for two residents. One resident with COPD and chronic respiratory failure had a continuous oxygen order, but was repeatedly observed without oxygen while staff interpreted the order inconsistently and the resident said he only used oxygen when lying down. Another resident with COPD was observed on nasal cannula oxygen, but no physician order for oxygen therapy was in place when reviewed, even though oxygen had been started and an LPN confirmed it required an order.
A resident with chronic pain syndrome, cancer history, osteoarthritis, spinal stenosis, and other conditions did not have a complete pain assessment or a fully individualized pain plan. The record did not consistently identify his pain history, addiction history, pain locations, goals, acceptable pain level, or the effectiveness of nonpharmacologic measures, and nurse notes for oxycodone and acetaminophen administration did not document where the pain was located. Staff interviews described different pain sites and goals, while the resident reported ongoing pain and said he had been using oxycodone for years.
Delayed Dental Services and Missed Routine Dental Care: A resident with multiple chronic conditions and intact cognition had signed consent for dental care and was referred for an external dental exam, X-rays, and prophy, but the scheduled dental visit was not completed as planned and later rescheduled. The resident then reported significant mouth pain with facial discomfort, swelling/redness, and pain rated as high as 8/10, while staff documented emergency dental evaluation, antibiotics, and ongoing pain management. Staff stated the resident should have been offered dental services sooner.
A resident with multiple chronic conditions and intact cognition reported that he was repeatedly served foods he disliked, including oatmeal for breakfast and turkey at lunch, and that cold cereal was never offered. During observation, staff did not provide a replacement when he رفض oatmeal, and his meal ticket did not reflect documented dislikes for turkey. Records showed the care plan lacked his likes and dislikes even though food preference assessments identified them, and staff interviews confirmed meal tickets and breakfast preferences were not consistently aligned with his stated preferences.
A facility failed to maintain infection control when a Yankauer suction tip was observed attached to the suction machine on a crash cart without sterile packaging. An LPN said the tip should not have been attached because it should be stored in a sterile container and could be used accidentally, and the DON stated she did not think it should be attached due to infection risk.
Call light system not functioning in a common bathroom and the Day Room. A resident reported pulling the bathroom cord and waiting more than 20 minutes without staff response, then calling a family member for help. Surveyors observed the bathroom activation did not appear on the overhead display or digital monitor, and the Day Room call light did not initially light above the door or register on the monitor. An RN said call lights should show on the computer and digital sign, but she did not know how to log in to view activations.
Inadequate bathroom ventilation and odors: The facility failed to maintain working ventilation in two shared resident bathrooms and two public bathrooms, with strong urine and feces odors noted on the 2nd floor. Several fan covers were dusty, multiple fans could not be heard or were not working, and one bathroom window was blocked by a bathtub setup that prevented it from being opened. The MTD confirmed the fans were not working properly and said the bathrooms needed functioning ventilation because they did not have usable windows.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment lacked proper hazard controls and sufficient monitoring, increasing the risk of accidents.
Failure to Provide Clean Hand Towels and Washcloths
Penalty
Summary
The facility failed to ensure clean linens were provided to residents on a daily basis, specifically hand towels and washcloths. During observations throughout the survey, no towel racks were found inside residents’ bathrooms or closets, and multiple resident rooms had no hand towels or washcloths present. In some rooms, the bathroom contained only paper towels, and the linen closets that were observed contained limited quantities of washcloths and hand towels that were kept locked. Resident interviews confirmed that residents were not receiving linen towels routinely and often had to ask staff for them. Several residents stated they only had paper towels in the bathroom, did not have cloth linens in their rooms, or had to keep a towel on their bed because there was no place to store it. Staff interviews also confirmed that towels were locked in linen closets, residents had to request them, and towels were not passed out. The DON stated that towel racks were in residents’ closets and that towels were replaced daily, but observations and resident interviews showed there were no towel racks in the closets or bathrooms and that residents were not receiving hand towels unless they asked for them.
Unsafe Smoking Assessment and Crash Cart Power Strip Deficiencies
Penalty
Summary
The facility failed to ensure Resident #11 was assessed to determine whether he remained safe to smoke independently after an incident of unsafe smoking. Resident #11 was admitted with diagnoses including type 2 diabetes and COPD, and his MDS documented that he was cognitively intact with a BIMS score of 15 out of 15 and no behaviors. His smoking care plan identified him as an independent smoker, and a smoking safety screen dated 12/18/25 stated he could safely store his own smoking materials, follow facility smoking policies, and smoke independently and unsupervised. On 1/17/26, a nursing note documented that Resident #11 was found in the basement conference room with a friend and staff believed he had been smoking. Staff reminded him about the safety risks and the facility smoking policy regarding smoking inside the building, and he was redirected back to his room. The record did not show that a new smoking safety screen was completed after this incident. During interviews, RN #2 and CNA #5 described that the resident had a sitter because of smoking-related behaviors, including attempting to smoke in his room and verbal aggression when redirected. SSD #2 stated she was not notified of the basement incident and said she would have completed a new smoking safety screen if she had known about it. The DON stated that unsafe smoking behaviors and refusal to follow smoking policies would trigger a new smoking safety assessment, but she determined no new assessment was needed because the resident was not observed actively smoking. The facility also failed to ensure medical grade power strips were readily available in all three emergency crash carts. On observation of the crash carts in the basement, first floor, and second floor, surveyors found commercial power strips in two carts and no power strip in one cart; none were medical grade at that time. The MTD later explained that medical grade power strips were important because commercial strips had 20 amps and could trap more heat, while medical grade strips had 15 amps and created less heat. The DON and ADON stated that crash carts were checked routinely, and the DON expected a medical grade power strip to be stocked in the crash carts for emergency equipment.
Improper Labeling of Medications in Medication Carts
Penalty
Summary
Drugs and biologicals were not properly labeled and dated in two medication carts, despite facility policy requiring medication labels to include the resident’s name and, when applicable, the expiration date. On the second floor medication cart, an LPN showed surveyors an Anoro Ellipta inhaler for Resident #62 that was stored in a labeled medication box but was not labeled on the device itself with the resident’s name or the date opened. The same cart also contained a Trelegy Ellipta inhaler for Resident #67 without the date opened on the device, and Systane long-lasting ophthalmic drops for Resident #60 without the resident’s name or date opened. On the first floor back hall medication cart, an RN showed surveyors several similarly stored medications that were not labeled on the individual containers with the resident’s name or the date opened. These included dimethyl fumarate for Resident #24, GenTeal severe ophthalmic gel for Resident #51, Anoro Ellipta inhaler for Resident #61, Albuterol sulfate HFA inhaler for Resident #40, and morphine sulfate oral solution for Resident #4. Staff interviews confirmed that medications should be labeled inside their boxes in case the boxes were damaged or separated, and the DON and ADON stated that unlabeled medications could be mixed up or separated from the box, creating the possibility of a medication error.
Food Served Cold, Bland, and Not Prepared as Ordered
Penalty
Summary
The facility failed to consistently serve food that was palatable in taste and at a safe and appetizing temperature. During meal service, residents reported that foods were cold, bland, overly salty, overcooked, gummy, or otherwise unappetizing. Multiple residents stated that vegetables were often overcooked, room trays on the second floor were barely warm, meals were too salty or lacked flavor, and condiments were not offered consistently. One resident said the lunch served was not good and another said the facility’s food was the worst he had experienced in other facilities. During observation of the lunch meal service, a resident told the dietary aide that the spinach did not taste right, and later another resident told the assistant director of nursing that lunch was horrible. A test tray served after the meal showed braised turkey roast that was dry and salty at 117 degrees Fahrenheit, rice pilaf that looked and tasted like plain rice at 118.9 degrees Fahrenheit, and creamed spinach that appeared plain, dark green, wet, and not creamy or cheesy at 120 degrees Fahrenheit. The observed food did not match the expected appearance or taste of the menu items. Record review and staff interviews showed the creamed spinach recipe called for butter, flour, salt, and nutmeg, but the cook said he did not have the ingredients and served frozen spinach with nothing added to it. The cook also stated the rice was made with chicken broth, garlic, and rice, while the recipe review and the NHA interview indicated the menu items should have been prepared to match the listed dishes. The NHA acknowledged resident concerns about food taste and said she did not know recipes were not being followed by dietary staff. The record also showed resident council and food committee minutes referenced food concerns, but food committee meetings did not take place in January or February 2026 as expected.
Kitchen Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen area because necessary maintenance repairs were not communicated and completed in a timely manner. During a walkthrough of the kitchen, surveyors observed visible burned marks on the wall behind the toaster, peeling wallpaper with sections missing near the ceiling, six holes in the wall near the spice rack, chipped paint on the ceiling along pipes near the toaster, brown spots on the ceiling above the oven and stove, duct tape on the swamp cooler system above the preparation table, and multiple stains on the wall above and below the three-compartment sink. In the dishwasher room, surveyors observed an exposed sheetrock sheet to the right of the dishwasher vent, a hole on the right side of the same vent, missing tile on the wall near the dishwasher, a loose vent above the dishwasher with missing screws, and chipped paint above the sink. Staff interviews showed that kitchen staff told the dietary manager about needed repairs but did not log them, and both kitchen staff said they did not know when the walls and ceiling were last cleaned. The maintenance director said maintenance requests were tracked in a software system, that department management was responsible for informing him of requests, and that the observed holes, chipped paint, and stains were not in the work order system.
Failure to Preserve Resident Belongings After Hospital Transfer
Penalty
Summary
The facility failed to ensure Resident #69 was able to retain personal belongings after discharge to the hospital. Resident #69 was admitted with diagnoses including quadriplegia and systemic lupus, and the MDS documented that he was cognitively intact with a BIMS score of 14 out of 15. After the physician determined the resident had phimosis requiring medical intervention and ordered transfer to the hospital, social services discussed the resident’s condition and possible readmission with his representative, including that he was going to start dialysis. Record review showed the resident’s representative later contacted the facility about a missing electronic tablet and was told the resident’s room had already been cleaned out. The admissions director stated she had left a voicemail advising that, since the resident had not been readmitted, his items would be packed up and stored, and the items were packed and stored in the basement before being disposed of after 57 days. The record did not contain progress notes showing the representatives were notified to pick up the belongings, and it also did not contain documentation of an initial call advising that the items could be disposed of in 30 days. Staff stated the notification to the representatives was verbal and that the admissions director did not usually document those calls.
Resident Council Dietary Concerns Not Addressed
Penalty
Summary
The facility failed to consider resident and family group views and act upon grievances and recommendations related to dietary concerns raised in resident council meetings. Five alert and oriented residents who regularly attended resident council meetings stated that dietary concerns were not included in the resident council meetings and were instead redirected to a separate food committee meeting, but it had been several months since they were given the opportunity to attend a food committee meeting. One resident stated that dietary concerns brought up in resident council meetings were redirected to the food committee meeting and were not addressed by staff. Record review showed that resident council meeting minutes documented dietary concerns being deferred to the food committee, including concerns from the January 2026 and February 2026 meetings. However, the facility could not provide documentation that the food committee meeting scheduled for 2/17/26 took place, and food committee notes showed the committee had not been conducted since 10/25/25. Staff interviews confirmed that dietary issues from resident council were redirected to the food committee, that the dietary manager who ran the food committee was no longer present, and that the NHA could not confirm whether food committee meetings had been held during the prior several months.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide ongoing, individualized activity programming for two residents whose care plans and assessments identified specific interests and needs. One resident, who had unspecified dementia, mood disturbance, anxiety, and was receiving hospice care, had a BIMS score of 9 and was dependent on staff for all ADLs. Her records showed that music, animals, news, favorite activities, books, and magazines were important to her, and her activity care plan called for assistance with activities of interest and encouragement to participate in individual activities as desired. Observations showed the resident sitting in the dining room during lunch with staff assisting her to eat, but no conversation was occurring with her. On two later observations, she remained lying in bed for hours without music, television, or other meaningful activity in her room. When a business office manager briefly visited and then left, the resident asked the manager to stay because she wanted company, but no care or activities staff came to provide a one-on-one activity or companionship. Her activity participation record documented independent activities and supplies for independent activities, but did not identify what those activities were, and it contained no documentation of group activities. A second resident had depression, difficulty walking, and chronic pain, was cognitively intact with a BIMS score of 15, and was independent with ADLs. Her MDS indicated it was very important to get fresh air when weather was good and to participate in favorite activities. She told the surveyor she had not been able to go on facility bus rides or shopping trips because the wheelchair lift on the facility bus had been broken for a long time. Her care plan noted that she liked community outings and included inviting and assisting her to activities of choice, but her activity participation record did not show participation in any outings. The activities director confirmed the resident wanted to attend outings and that the broken wheelchair lift prevented her from doing so.
Missing Orders and Diet Mismatch for Resident with Diabetes
Penalty
Summary
Resident #67, a cognitively intact resident admitted after hospitalization for vertigo and continued dizziness, had diagnoses including type 2 diabetes mellitus with diabetic neuropathy and COPD. On admission, the resident had an insulin pump and a Dexcom freestyle glucometer that she said transmitted blood glucose results to her phone, and she stated she was able to manage these devices herself. The hospital discharge record included orders for insulin aspart via Omnipod pump and a carbohydrate-controlled diet with 25% to 50% of calories from carbohydrates at each meal. The facility’s February 2026 computerized physician orders did not include an order for the insulin pump, an order to monitor blood glucose levels, or an order to monitor the pump for dysfunction or complications. The resident’s record also showed a regular diet order rather than the carbohydrate-controlled diet listed in the hospital discharge records. The resident told surveyors she had been requesting a carbohydrate-controlled diet since admission but was receiving regular meals instead, and she said staff had not asked to see her blood sugar readings from her phone. Survey observations showed the resident received regular meals, including dinner trays and breakfast items that were not carbohydrate controlled. The record review found no documentation that the facility had attempted to obtain the missing monitoring orders from the physician before the survey. Staff interviews confirmed there were no physician orders in the EMR for the insulin pump or blood glucose monitoring during the initial review, and the ADON stated she had not yet reviewed the resident’s EMR for complete admission orders.
Failure to Consistently Reposition and Offload Heels for a Resident With Pressure Injuries
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent additional pressure injuries for one resident with existing wounds. The resident was age greater than 65, had diagnoses including unspecified dementia, mood disturbance, and anxiety, and was documented as moderately cognitively impaired, dependent on staff for all ADLs, at risk for pressure injuries, and already had at least one unhealed pressure injury. Observations showed the resident was not consistently repositioned and was not consistently provided protective heel boots or timely incontinence care. On one occasion, the resident was seen in a wheelchair without protective boots, with sock feet resting directly on the foot pedals. During a continuous observation in bed, the resident remained on her back for hours without repositioning, with no positioning wedges in the room and heels resting directly on the mattress. On another observation period, the resident again remained on her back in bed without staff entering to provide incontinence care or repositioning. When nurses later entered to perform wound care, the resident’s heels were still without protective boots and resting directly on the mattress, and the resident was found wet when the brief was opened. The resident’s care plan identified a deep tissue injury to the right heel and a stage 3 pressure ulcer to the sacrum, with interventions including heel offloading boots in bed and in the chair, offloading heels, and frequent turning and repositioning. The record also showed a new right heel pressure injury and later a new sacral pressure injury, with orders and notes referencing repositioning schedules, frequent rounding, pillows, wedges, and heel offloading. Staff interviews confirmed the resident was high risk due to immobility and incontinence, was supposed to be checked frequently, and should have had heel protectors on at all times and repositioning every two hours. Despite these documented interventions and expectations, the observations showed the interventions were not consistently carried out.
Failure to Match Oxygen Use to Orders and Missing Oxygen Order
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents by not following physician orders for oxygen therapy. One resident had diagnoses including acute and chronic respiratory failure, COPD, MS, and neuromuscular dysfunction of the bladder, and his MDS showed he required oxygen therapy. Although his February 2026 physician order directed continuous oxygen at 2 to 5 LPM via nasal cannula to keep oxygen saturation between 88% and 92%, he was observed multiple times without oxygen or a nasal cannula while in the dining room, in his room, and while traveling in his powered wheelchair. That resident told staff he used oxygen when lying down because he could not breathe when lying down and needed it for naps and sleep. Staff interviews showed differing interpretations of the order: one RN said the resident did not need continuous oxygen if his saturation was within the ordered range, another RN said the physician had not been notified that the resident was not wearing oxygen continuously, and the DON said the order should specify oxygen at night and that the resident did not need to wear oxygen if saturations were within parameters. The resident’s care plan noted he preferred to wear supplemental oxygen at night. A second resident with diagnoses including type 2 diabetes mellitus with diabetic neuropathy and COPD was observed wearing nasal cannula oxygen set at 3 LPM and later 2.5 LPM. Review of the February 2026 physician orders showed no order for oxygen therapy at the time of the survey review, even though a progress note documented that oxygen at 2 LPM via nasal cannula had been started. An LPN confirmed oxygen is considered a medication and requires a physician’s order, and she could not locate an order for the resident’s oxygen use.
Incomplete Pain Assessment and Inconsistent Pain Documentation
Penalty
Summary
The facility failed to provide an effective pain management regimen for one resident who had chronic pain syndrome and multiple other diagnoses, including cancer, osteoarthritis, spinal stenosis, COPD, peripheral vascular disease, acute kidney failure, and depression. The resident was cognitively intact and reported ongoing pain, but the pain assessments in the record did not fully capture his history of pain and treatment, his history of addiction, his pain characteristics, or the impact of pain on his quality of life. The assessments also did not identify his goals for pain management, his acceptable pain level, or all of his pain locations. The resident told surveyors that he had been prescribed oxycodone for years after neck surgery, that he could no longer ride his bike because of pain, and that he had pain in his hernia area, abdomen, and both knees. He stated his current pain level was 6 out of 10 and sometimes increased to 8 out of 10, and he said his goal was to have no pain and return to his previous lifestyle as much as possible. The record showed pain assessments dated in October 2025, January 2026, and February 2026, but sections for treatment, side effects, effectiveness of pain medications, and non-medication interventions were left blank in parts of the assessments. The care plan listed some pain-related diagnoses and interventions, but it did not include non-pharmacological interventions, monitoring for pain medication effectiveness, or monitoring for opioid side effects. Physician orders showed multiple changes to oxycodone dosing, along with orders for Cymbalta, gabapentin, acetaminophen, and nonpharmacological interventions. However, the record did not show documentation of whether the non-pharmacological interventions were effective, and nurse notes documenting oxycodone and acetaminophen administration did not identify where the pain was located when the medications were given. Physician notes also documented that the resident had pain in his hands, knees, and hernias, that his pain control was unclear, and that he had tested positive for methamphetamine and admitted to buying oxycodone off the street. Staff interviews reflected differing descriptions of the resident’s pain locations and goals, with some staff identifying pain in the hands, wrists, lower back, legs, or abdomen, while the documented assessments did not consistently capture those details.
Delayed Dental Services and Missed Routine Dental Care
Penalty
Summary
The facility failed to provide timely dental services for one resident who had documented dental needs and later reported significant mouth pain. The resident was cognitively intact, used a wheelchair, and had diagnoses including osteoarthritis, chronic pain syndrome, hyperlipidemia, polyneuropathy, insomnia, major depressive disorder, generalized anxiety disorder, and post traumatic anxiety disorder. The resident had signed consent for dental services, and a physician had ordered an external dental exam, X-rays, and a prophy within one week after noting the resident had been asked not to return to a prior dental office because of behaviors related to obtaining local anesthesia. The resident was placed on the facility dentist schedule, but the appointment was not completed as planned. Social services documented that the resident was scheduled for a dental visit but was out of the facility, and later documentation showed the resident had also been on the dentist schedule on another date but was not seen and would be rescheduled. The record also showed a dental emergency evaluation form documenting upper right and lower right mouth pain rated 7 out of 10 and present for seven days, with no antibiotics or pain medication prescribed at that time. Nursing later documented that the resident was seen by the dentist for recent pain in the gums and mouth and was started on oral antibiotics. The resident continued to have pain complaints involving the right ear, jaw, and neck, with swelling or redness noted in the gum or mouth area. The physician was notified and additional pain medication was ordered. Social services staff stated the dentist came to the facility every other month, residents were generally seen annually or quarterly depending on insurance, and emergency dental needs were supposed to be addressed sooner. Staff also stated the resident should have been offered dental services sooner than what was offered. During interview, the resident was observed in visible pain on the right side of the face and reported an 8 out of 10 pain level, and white caked substance was observed on the upper front teeth.
Resident Meals Not Served According to Food Preferences
Penalty
Summary
The facility failed to ensure meals were served according to a resident’s food preferences. Resident #37 was cognitively intact, independent with eating, and had multiple diagnoses including chronic pain syndrome, rectal/rectosigmoid cancer, obesity, MDD, COPD, PVD, osteoarthritis, spinal stenosis, acute kidney failure, BPH, and hypoxemia. The facility policy required staff to interview residents about food preferences, document those preferences in the care plan, and offer a variety of foods at each scheduled meal. Resident #37 told surveyors that he did not receive the foods he wanted at meals. He stated he hated oatmeal but was always given oatmeal for breakfast, wanted cold cereal but it was never offered, and disliked turkey but was served turkey. During a breakfast observation, he was served pancakes, bacon, and oatmeal; when he said he did not want the oatmeal, staff did not offer a replacement and left the oatmeal on the table. During a lunch observation, his meal ticket did not show his dislike for turkey, and he was served braised turkey roast, rice pilaf, creamed spinach, and spice cake. Record review showed the nutrition care plan did not include his likes and dislikes, although food preference assessments documented that he did not like turkey and cabbage. Staff interviews indicated CNAs were responsible for completing meal tickets and offering substitutions when residents did not want menu items, but breakfast orders were not routinely taken unless a preference was already entered. The NHA stated the facility did not have a DM at the time, that the RD was responsible for completing assessments and entering likes and dislikes, and that she did not know Resident #37’s meal ticket did not match his preferences.
Unsterile Yankauer suction tip attached to crash cart suction machine
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of infectious diseases. During observation on 2/25/26 at 4:00 p.m., a Yankauer suction tip was seen attached to the suction machine on the second floor crash cart, and it was not inside its sterile packaging. During interviews, an LPN stated she did not know what to turn the suction machine to in an emergency and said the Yankauer suction tip was not supposed to be attached to the suction machine because it should be stored in a sterile container and might accidentally be used. The ADON and DON later stated that checking the suction machine was part of the night nurse's crash cart duties, and the DON said that although it might be considered best practice to have a Yankauer suction tip attached for emergency access, she did not think it should be attached because of infection risk.
Call Light System Not Functioning in Common Bathroom and Day Room
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly in the common bathroom near the main dining room in the basement and in the Day Room on the first floor. A resident who was newly admitted reported that he pulled the bathroom cord for help and waited more than 20 minutes without staff responding, so he used his cell phone to call a family member to contact the facility for assistance. During observation, the bathroom call light was activated but there was no notification above the door, and the digital hanging monitor did not display the activation. In the Day Room, the call light cord was clipped to the wall, and when it was pushed, it did not initially light up above the door or appear on the digital hanging monitor. On a second push, the light above the door did illuminate, but the monitor still did not show the activation. RN #1 stated that call lights should register on the computer monitor and the digital sign, but she did not know how to log into the computer to view the rooms that had pulled the cords. The NHA stated the facility was not aware of the issue and that the basement bathroom should have notified staff on the first floor; the MTD later stated the bathroom call light had been fixed and now displayed on the board and computer.
Inadequate Bathroom Ventilation and Odors
Penalty
Summary
The facility failed to provide adequate outside ventilation through windows or mechanical ventilation in two of three common bathrooms and two resident bathrooms, affecting eight residents. On 2/23/26, the 2nd floor was odorous, and the shared bathroom for two rooms had strong urine and feces odors, no windows, and a ventilation fan that could not be heard; the fan cover also had dust built up on it. On 2/24/26, the shared bathroom for another two rooms again had strong urine and feces odors with a dusty fan cover, and the shared bathroom for two other rooms continued to have the same odors. The men's public bathroom on the second floor had strong urine and feces odors, no windows, and a ventilation fan that could not be heard, and the women's public bathroom on the second floor also had strong urine and feces odors. The women's public bathroom had a window, but it was high on the wall and blocked by a bathtub with bars built up above the bathtub lip, preventing access to open it. On 2/25/26, the maintenance director observed the men's and women's public bathrooms and found the ventilation fans were not working. He also observed the shared bathroom for two rooms and found its ventilation fan was not working, and observed another shared bathroom fan cover was dirty and the fan was not working properly, only pulling in a little air and not working at full strength. The maintenance director stated the bathrooms all had individual ventilation fans, that he checked them monthly, that the women's bathroom window had been closed because opening it made the hallway cold, and that because the bathrooms did not have windows, the ventilation fans needed to work properly.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of appropriate hazard controls and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
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 83 citations issued within 25 miles in the last 12 months — including the 2 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 Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bear Creek Senior Living | 0.9 mi | ★★★★★ | 1 | 0 |
| Gardens, The | 0.9 mi | ★★★★★ | 12 | 0 |
| Brookdale Skyline | 1.1 mi | ★★★★★ | 1 | 0 |
| Kiowa Hills Rehabilitation And Nursing, Llc | 1.8 mi | ★★★★★ | 8 | 0 |
| The Healthcare Resort Of Colorado Springs | 2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.