Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center At Foresight Llc, The during CMS and state inspections, most recent first.
Failure to Assess Self-Administration of Medications: The facility left medications at the bedside for four residents without completing the required clinical appropriateness process first. One resident with hemiplegia, aphasia, COPD, and cognitive impairment had Voltaren at the bedside without an assessment or order for that medication; another resident with COPD had an albuterol inhaler and Ayr nasal gel at the bedside without a care plan, order, or assessment; a third resident with multiple chronic conditions and moderate cognitive impairment had saline nasal spray and Ayr nasal gel at the bedside without the required documentation; and a fourth resident with a femur fracture and hypertension had AlgaeCal at the bedside without a complete care plan, order, or timely assessment.
Antibiotics were ordered and given before urine C&S results were available for three residents being treated for possible UTIs. One resident had positive UA findings and later culture results showing probable contamination, while two others had positive UA findings but no C&S results in the record. The DON stated the C&S should come back before starting antibiotics, yet the physician ordered treatment first and the residents received multiple doses.
The facility failed to ensure that residents or their representatives were adequately informed about the nature and implications of the arbitration agreement before signing it. Admissions coordinators did not provide necessary information, and some residents were under the influence of pain medication during the admission process, leading to residents signing a binding legal document without fully understanding their rights and options.
The facility failed to ensure a resident received professional standards of care by not notifying the provider of significant weight changes as required. Despite multiple significant weight fluctuations documented in the EMR, there was no evidence that the physician was notified, as mandated by the provider's orders. Staff interviews revealed inconsistencies in weighing processes and a lack of awareness about the resident's weight changes.
Failure to Assess Clinical Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for four residents who had medications kept at their bedsides or available for self-use. The report states that the facility policy required an interdisciplinary determination of clinical appropriateness and a nursing assessment of each resident’s mental and physical ability, including understanding labels, knowing the purpose and dosage, removing and ingesting the medication, and recognizing risks and adverse consequences. For the four residents reviewed, the record did not show that these requirements were completed before the medications were left available for self-administration. Resident #1 had diagnoses including hemiplegia/hemiparesis following cerebral infarction, aphasia, acute respiratory failure, COPD, and atrial fibrillation, and was moderately cognitively impaired with a BIMS score of 10. A container of Voltaren was observed on the bedside table on multiple occasions, and the resident said his wife assisted him with the cream when needed. The care plan and self-administration assessment documented only Biotene and fluticasone, and the record did not show an assessment or physician order for Voltaren at the time it was observed at the bedside. Resident #40 had COPD and was cognitively intact with a BIMS score of 13, but an albuterol inhaler and Ayr nasal gel were observed on the bedside table and within reach. The record did not reveal a self-administration care plan, physician order, or assessment for either medication at the time they were observed. Resident #28 had arthritis, type 2 diabetes, hypertension, edema, and pulmonary disease, was moderately cognitively impaired with a BIMS score of 12, and had saline nasal spray and Ayr nasal gel on the bedside table; the record did not show a care plan, physician order, or assessment for those medications. Resident #15 had a femur fracture and hypertension, was moderately cognitively impaired with a BIMS score of 11, and had AlgaeCal on the bedside table; the care plan and physician order were incomplete, and the assessment was not completed until after the concern was identified during the survey.
Antibiotics Started Before Urine Culture Results Were Available
Penalty
Summary
The facility failed to ensure urine culture and sensitivity (C&S) results were obtained before antibiotics were ordered or administered for three residents being treated for possible urinary tract infections. The facility’s antibiotic stewardship policy stated that the infection preventionist or designee would review whether appropriate tests such as cultures were obtained before ordering antibiotics, and would monitor antibiotic use and changes during treatment. Resident #72 was admitted with diagnoses including metabolic encephalopathy, heart failure, acute respiratory failure, and diabetes, and was moderately cognitively impaired. Her urinalysis showed positive nitrites and leukocytes, and the urine culture later showed multiple bacterial morphotypes, indicating probable contamination and recommending recollection if clinically indicated. Before those culture results were received, the physician ordered Macrobid for a UTI, and the resident received two doses of the antibiotic. Resident #20 was moderately cognitively impaired and had an antibiotic use care plan initiated for a UTI. Her urinalysis was positive for nitrites, but there were no laboratory results for a UA C&S in the record. A physician ordered Macrobid for an uncomplicated UTI before any C&S results were received, and the resident received five doses before the medication was later discontinued. Resident #60, who was moderately cognitively impaired and required maximum assistance with ADLs, also had a UTI listed on the antibiotic use care plan. Her urinalysis was positive for leukocytes, but no UA C&S results were in the record. A physician ordered cefuroxime axetil for a UTI before culture results were available, and the MAR showed the resident received five doses of Macrobid.
Failure to Inform Residents About Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents or their representatives were adequately informed about the nature and implications of the arbitration agreement before signing it. Specifically, the facility did not thoroughly explain the arbitration agreement in a manner that the residents and their representatives could understand. Additionally, the residents were not accurately informed that the arbitration agreement was binding and that they had the right to rescind the agreement within 90 days of signing it. This failure affected five out of six sampled residents, who were not made aware of these critical details during the admission process. Interviews with the admissions coordinators revealed that they did not provide residents with the necessary information about the arbitration agreement. The admissions coordinators admitted that they did not inform residents about the 90-day rescission period and were under the impression that the arbitration agreement was not binding. This misinformation was passed on to the residents, who signed the agreement without fully understanding its implications. Some residents were also under the influence of pain medication during the admission process, further complicating their ability to comprehend the agreement. Resident interviews corroborated these findings, with several residents stating that they were not aware of the arbitration agreement or the rescission period. Some residents were in pain or highly medicated at the time of signing, making it difficult for them to understand what they were signing. The facility's failure to provide clear and accurate information about the arbitration agreement led to residents signing a binding legal document without fully understanding their rights and options.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to ensure that Resident #18 received professional standards of care, specifically in the management of edema and significant weight changes. The resident, who was over 65 years old and had diagnoses including takotsubo's syndrome, heart failure, and lymphedema, had an order for daily weights and provider notification for specific weight changes. Despite this, the facility did not document any notifications to the provider for multiple significant weight changes recorded in the resident's electronic medical record (EMR) over a period of several months. The facility's policies on edema and weight loss interventions required daily weights and provider notifications for significant changes, but these were not followed. The resident's care plan also failed to document the resident's edema, and daily weights were not included in the documented interventions. The EMR showed multiple instances of significant weight changes, but there was no documentation indicating that the physician was notified of these changes, as required by the provider's orders. Interviews with staff, including a CNA, RN, RD, and the DON, revealed that there were inconsistencies in the process of weighing residents and a lack of awareness about the resident's significant weight fluctuations. The RD and DON both acknowledged that provider orders should be followed and that the provider should have been notified of the significant weight changes. However, there was no evidence in the EMR to indicate that these notifications occurred, leading to a failure in providing the required standard of care for Resident #18.
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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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Nursing homes near Grand Junction
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Villa Grande Care Center | 1.6 mi | — | 1 | 1 |
| Red Cliffs Post Acute | 2.1 mi | — | 1 | 0 |
| Larchwood Health And Rehab Llc | 2.1 mi | — | 5 | 0 |
| Eagle Ridge Post Acute | 3 mi | — | 4 | 1 |
| Mantey Heights Rehabilitation & Care Center | 3.2 mi | — | 2 | 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 August 2026) and official state health department websites.