Cycle 1
Health 2024-11-21 · Fire 2024-11-21
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Boulder, CO
Winding Trails Post Acute
1-star overall rating with 1-star inspections with abuse icon flag with $101,829 in total fines with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2800 Palo Pkwy, Boulder, CO
(303) 440-9100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1989-11-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.71
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,626
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9922
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.58
Baseline 20.12% · Performance 18.85% · Measure score 5.58 · Achievement 5.58 · Improvement 3.63
Healthcare-associated infections
4.98
Baseline 6.90% · Performance 6.35% · Measure score 4.98 · Achievement 4.98 · Improvement 2.42
Total nurse turnover
3.89
Baseline 85.59% · Performance 58.93% · Measure score 3.89 · Achievement 1.16 · Improvement 3.89
Adjusted total nurse staffing
1.23
Baseline 3.46 hours · Performance 3.43 hours · Measure score 1.23 · Achievement 1.23 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.23% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 11.86% · Lower 95% interval 7.48% |
| Discharge to community | 47.5% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 43.86% · Lower 95% interval 36.09% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 68.18% |
53.69%
14.5 pts better
|
Numerator 30 · Denominator 44 |
| Discharge mobility score | 56.82% |
50.94%
5.9 pts better
|
Numerator 25 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 59 · Adjusted rate 1.95% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 9.38% |
8.2%
1.2 pts better
|
Numerator 6 · Denominator 64 |
| Staff flu vaccination coverage | 57.14% |
42%
15.1 pts better
|
Numerator 44 · Denominator 77 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 32 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 61.54% |
25.2%
36.3 pts better
|
Numerator 24 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.9 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
93.5%
5.6 pts worse
|
93.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 89.4% · Q3 89.5% · Q4 83.6% · 4Q avg 87.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.7% |
94.7%
16 pts worse
|
95.5%
16.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.4%
2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.5% · Q3 1.3% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
7.4%
5.4 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 3.1% · Q4 2.9% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
5.0%
3.8 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
11.2%
1.1 pts worse
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 10.0% · Q3 12.7% · Q4 14.3% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
20.6%
1.1 pts worse
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 22.5% · Q3 19.1% · Q4 24.0% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.3% |
15.2%
5.9 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 15.1% · Q3 9.2% · Q4 2.7% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
14.6%
3.7 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 13.8% · Q3 11.3% · Q4 1.4% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.8%
0.2 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 2.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
22.4%
3.8 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 30.1% · Q3 24.6% · Q4 21.9% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
3.7%
1.6 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 7.2% · Q3 6.1% · Q4 1.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.4% |
76.4%
10 pts worse
|
81.7%
15.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.4% · Q2 71.3% · Q3 66.3% · Q4 69.1% · 4Q avg 66.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
12.8%
5.1 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
1.5%
4.1 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.4% · Q3 6.9% · Q4 5.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.2% |
75.6%
15.4 pts worse
|
79.7%
19.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
20.3%
2.8 pts worse
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 19.6% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-15 · Fire 2023-06-15
29 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-04-19 · Fire 2022-04-19
31 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-30
F · Potential for more than minimal harm
2024-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-11-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-21
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-11-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-11-21
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-12-30
F · Potential for more than minimal harm
2023-06-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-06-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-06-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-06-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-15
F · Potential for more than minimal harm
2022-04-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-14
F · Potential for more than minimal harm
2022-04-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-09
F · Potential for more than minimal harm
2024-11-21
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-11-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-10-15
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-11-01
J · Immediate jeopardy
2024-03-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-17
G · Actual harm
2024-03-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-29
G · Actual harm
2024-03-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-07
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-03-07
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-07
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-07
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-21
F · Potential for more than minimal harm
2023-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-11-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-18
F · Potential for more than minimal harm
2023-06-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-15
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-06-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-15
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-06-15
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-15
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-08-08
G · Actual harm
2023-03-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-26
L · Immediate jeopardy
2022-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-18
L · Immediate jeopardy
2022-04-19
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-14
L · Immediate jeopardy
2022-04-19
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-06-14
J · Immediate jeopardy
2022-04-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-14
G · Actual harm
2022-04-19
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2022-06-14
G · Actual harm
2022-04-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-06-14
G · Actual harm
2022-04-19
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2022-06-14
G · Actual harm
2022-04-19
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2022-06-14
G · Actual harm
2022-04-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-06-14
F · Potential for more than minimal harm
2022-04-19
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-04-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-04-19
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-06-14
Penalties and ownership
What sits behind the stars
$90,659
2024-03-07
Fine
Fine · fine $90,659
Fine
$0
2024-03-07
Payment Denial
Payment Denial · denial start 2024-04-05 · 85 days
85 day denial
$11,170
2023-03-23
Fine
Fine · fine $11,170
Fine
Ownership
Panther Master Tenant, LLC
5% Or Greater Direct Ownership Interest · Organization
Adlesich, Robert
W-2 Managing Employee · Individual
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Horton, Christopher
Contracted Managing Employee · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
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#3
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5-star overall rating with 4-star inspections with $49,202 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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