7Risk Axes

National percentile · lower = less risk · staffing gap is context only (not in composite)

How we calculate
SeverityElevated

95th national percentile — 20.0% high-severity citations

ChronicityModerate

46th national percentile — 1 repeat citations

Staffing integrityClean

None on file

Fire safetyElevated

16 citations

Weekend staffing dropWatch

57th national percentile — 16.3%

Contract staff shareLow

17th national percentile — 0.0%

Clinical trendElevated

91th national percentile — 3/5 measures worsened

Staffing gapN/A

Not on file

Recent Health Violations

Health inspection citations from official Medicare records

5 citations on file
F-0760
D
Ensure that residents are free from significant medication errors
Minimal Harm

Ensure that residents are free from significant medication errors.

Survey date: Dec 1, 2025 · Isolated — no actual harm with potential for more
F-0880
D
Provide and implement an infection prevention and control program
Minimal Harm

Provide and implement an infection prevention and control program.

Survey date: Dec 19, 2024 · Isolated — no actual harm with potential for more
F-0689
G
Ensure that a nursing home area is free from accident hazards and provid…
Actual Harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey date: Aug 17, 2023 · Isolated — actual harm
F-0758
D
Implement gradual dose reductions(GDR) and non-pharmacological intervent…
Minimal Harm

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.

Survey date: Aug 6, 2019 · Isolated — no actual harm with potential for more

Recent Fire Safety Violations

Fire safety inspection citations from official Medicare records

16 citations on file
F-0321
F
Ensure that special areas are constructed so that walls can resist fire …
Potential Harm

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Survey date: Dec 19, 2024 · Widespread — no actual harm with potential for more
F-0324
D
Provide properly protected cooking facilities
Minimal Harm

Provide properly protected cooking facilities.

Survey date: Dec 19, 2024 · Isolated — no actual harm with potential for more
F-0345
F
Have approved installation, maintenance and testing program for fire ala…
Potential Harm

Have approved installation, maintenance and testing program for fire alarm systems.

Survey date: Dec 19, 2024 · Widespread — no actual harm with potential for more
F-0351
F
Install an approved automatic sprinkler system
Potential Harm

Install an approved automatic sprinkler system.

Survey date: Dec 19, 2024 · Widespread — no actual harm with potential for more

Better Nearby Options

Within 25 km · sorted by overall risk percentile

Full nearby list
Facility
CMS
Risk %ile
Tier
SOUTH PLATTE REHABILITATION AND NURSING LLC
11.9 km · BRUSH, CO
CMS
46th
Risk %ile
Similar risk