Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Silver Heights Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Eight rooms were found without hand towels, and two residents reported not receiving towels, with one using personal clothing to dry hands. Although towels were available in facility storage areas, CNAs did not consistently deliver them to resident rooms as required by policy.
Surveyors identified that multiple medications and vaccines, including Tubersol, Hepatitis B vaccine, Prevnar, Fluzone, Spikevax, and Basaglar insulin pens, were stored in a medication refrigerator that was above the recommended temperature range. The DON confirmed there was no temperature log or documentation of regular checks, and it was unclear how long the refrigerator had been out of range.
Surveyors identified multiple infection control deficiencies, including improper hand hygiene and clean technique during wound care by the DON, unsanitary room cleaning practices by housekeeping staff who failed to change cleaning materials between resident areas, and inadequate laundry procedures where reusable gowns were not washed after each use and uncleanable hair ties were used. Additionally, residents' personal items such as toothbrushes were found unlabeled and stored together in shared rooms, violating facility policy and infection control standards.
Two residents were not protected from physical abuse by other residents, resulting in substantiated incidents where one resident was grabbed and shaken by another, and another was pushed from a wheelchair, sustaining injuries. Both incidents involved residents with cognitive impairments and behavioral histories, and staff intervention occurred after the abuse had already taken place.
A resident with severe physical and cognitive impairments did not receive timely toileting assistance or incontinence care, as staff failed to check or assist the resident for extended periods despite care plan requirements and facility protocols. Observations showed the resident was left soiled for over five hours, and staff interviews confirmed that checks should have occurred every two hours.
A resident with multiple medical conditions experienced persistent lower jaw pain and was referred by the facility dentist for an alveoloplasty. Despite this referral, there was no documentation that the facility assisted the resident in obtaining the recommended dental procedure, and the resident reported waiting for months without communication about her appointment.
A resident with a left hand contracture did not receive appropriate contracture management, as the care plan failed to address the condition and recommended interventions such as a palm guard were not implemented. Staff were unaware of the contracture management needs, and the facility lacked a system to track therapy recommendations, resulting in the resident not receiving necessary preventive measures.
A resident with severe cognitive and physical impairments experienced multiple unwitnessed falls resulting in injuries, but the facility did not identify the root cause or implement effective person-centered interventions. The care plan and records lacked documentation of new or non-pharmacological strategies after each fall, and staff were not consistently aware of the resident's fall risk or required interventions. Instead, medication changes were made without documented justification of behavioral symptoms prior to the falls.
Two residents were not properly offered or documented for annual influenza and pneumococcal vaccinations as required by facility policy. One resident was not reoffered the pneumonia vaccine, and another did not receive the pneumococcal vaccine after providing consent. Staff interviews confirmed gaps in annual vaccine offering and documentation.
A resident consistently refused her anticoagulant medication, Eliquis, due to concerns about bleeding during dialysis. Despite being educated on the importance of the medication, the refusals were documented but not consistently reported to the physician. The facility's protocol required notifying the provider after multiple refusals, which was not followed, leading to a deficiency.
A resident with dementia was physically abused by another resident in a LTC facility, resulting in a swollen and bleeding lip. The facility's policy mandates protection from harm, but staff lacked specific training to handle resident behaviors, contributing to the incident. The aggressor had a history of behavioral issues, and the victim had been involved in previous altercations, indicating a pattern of vulnerability.
Two residents in an LTC facility did not receive timely assistance with activities of daily living. One resident, with cognitive impairments and dysphagia, was not encouraged or cued during meals and was left without incontinence care for four hours. Another resident, with muscular dystrophy, reported not being changed for over three hours during a night shift, resulting in sleeping in urine. The care plans lacked specific interventions for these issues, and staff interviews confirmed the deficiencies.
A facility failed to prevent the drug diversion of Ativan for a resident due to a lapse in conducting a required narcotic count during a shift change. This resulted in the discovery of 44 missing Ativan tablets. An investigation involved drug testing of the nurses with access to the medication cart, all of whom tested negative. The incident was reported to the police and the State Agency.
The facility failed to accurately document skin assessments for two residents, leading to deficiencies. One resident had an open wound on the left foot, but records inaccurately noted a rash on the right foot, with no treatment interventions documented. Another resident was admitted with an unstageable pressure injury, but the admission assessment inaccurately documented intact skin, and progress notes lacked documentation of the injury. These issues were acknowledged by the facility's leadership team.
Failure to Provide Daily Hand Towels in Resident Rooms
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for residents in eight out of 36 rooms by not supplying hand towels on a daily basis. Observations conducted over two days revealed that multiple shared rooms did not have any towels available for residents. Specifically, at various times, surveyors noted the absence of towels in these rooms, indicating a pattern of non-compliance with the facility's own Homelike Environment policy, which emphasizes person-centered care and attention to residents' comfort and personal needs. Interviews with residents confirmed the deficiency, as one resident reported having to use personal clothing to dry hands due to the lack of towels, and another stated that towels were not provided in their room. Staff interviews revealed that while towels were available in the laundry room, shower rooms, and linen closets, CNAs were responsible for delivering and replacing towels daily. Despite previous education provided to CNAs on this responsibility, the deficiency persisted, as evidenced by the observations and resident reports.
Improper Storage of Medications and Vaccines Due to Elevated Refrigerator Temperature
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage and labeling of drugs and biologicals in the medication storage room. During an observation, the medication storage refrigerator was noted to be at 50 degrees Fahrenheit, which is above the recommended safe storage range of 36 to 46 degrees Fahrenheit for several medications and vaccines, including Tubersol, Hepatitis B vaccine, Prevnar, Fluzone, Spikevax, and Basaglar insulin pens. These items were found inside the refrigerator at the time of inspection. Interviews with the DON revealed that there was no documentation or temperature log to confirm that the refrigerator was being checked regularly by staff, as required. The DON was unaware of how long the refrigerator had been operating above the safe temperature range. The facility's policy required contacting the pharmacy for instructions regarding discontinued, outdated, or deteriorated medications, but there was no evidence that this process was followed in relation to the temperature deviation.
Widespread Infection Control Failures in Hand Hygiene, Room Cleaning, Laundry, and Personal Item Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program across all units, as evidenced by multiple observed lapses in infection control practices. During wound care for three different residents, the DON did not establish or maintain a clean field for wound supplies, failed to perform hand hygiene before donning gloves and gowns, and did not change gloves or perform hand hygiene after handling soiled dressings and before handling clean supplies. These actions were inconsistent with CDC guidelines and the facility's own policies, which require hand hygiene before and after glove use, and the establishment of a clean field for wound care. Housekeeping staff did not follow sanitary cleaning procedures in resident rooms. A housekeeper was observed using the same disinfectant rag and gloves to clean multiple surfaces and resident areas within a shared room, without changing rags or gloves between areas. The mop head was not changed between cleaning different resident zones, and high-touch areas such as light switches and door knobs were not cleaned. These practices were not in line with CDC recommendations or the facility's cleaning policy, which require separate cleaning materials for each resident area and attention to high-touch surfaces. Laundry procedures were also found to be unsanitary. The laundry aide used reusable gowns that were not washed after each use and used uncleanable hair ties to secure gown sleeves, both of which created potential for cross-contamination. Additionally, the facility did not ensure that laundry from residents on isolation precautions was washed in a separate cycle, as recommended by CDC guidelines. Furthermore, residents' personal items, such as toothbrushes and toiletries, were found unlabeled and stored together in shared rooms, contrary to facility policy and infection control standards.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, resulting in substantiated incidents of abuse. In the first incident, a resident with severe dementia, who had a history of reaching out and grabbing people, was seated in his doorway when another resident walked by. The seated resident grabbed the passing resident's wrist and did not let go when asked. In response, the passing resident grabbed the seated resident by the back of the neck and shook him. This action was witnessed by the staffing coordinator, who immediately intervened. The investigation determined that the action was willful and constituted physical abuse. The resident who was the victim in this incident had diagnoses of dementia and Alzheimer's disease, with significant cognitive and memory impairments, and a history of involvement in physical altercations. The assailant had Parkinson's disease and moderate cognitive impairment, with a documented history of verbally and physically aggressive behavior toward others. Both residents had care plans addressing their behavioral issues, but the incident still occurred, indicating a failure to prevent abuse. In the second incident, two residents began arguing loudly in a common room. One resident, who had moderate cognitive impairment and a history of verbal aggression, attempted to push the other's wheelchair but instead pushed the resident directly, causing him to fall and sustain two skin tears and later bruising. Staff separated the residents and provided first aid. The investigation substantiated that the physical abuse was willful. The victim in this case had moderate cognitive impairment and required assistance with daily activities, while the assailant had dementia with behavioral disturbances and required substantial assistance with care.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care to a resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, and unsteadiness, required substantial assistance with activities of daily living such as toileting and personal hygiene. Observations revealed that during a nearly four-hour period, staff entered the resident's room but did not check for incontinence or offer toileting assistance. On another day, the resident was moved between various activities and meals without being checked for incontinence or offered toileting assistance for over five hours. When finally checked, the resident was found soiled with urine and a bowel movement. Review of the care plan indicated the resident required supervision and cueing with ADLs, including prompt incontinence care and routine skin checks. However, staff did not follow these interventions, as evidenced by the lack of timely checks and care. Staff interviews confirmed that the resident should have been checked every two hours, but this protocol was not followed, resulting in prolonged periods without necessary incontinence care.
Failure to Follow Up on Dental Referral for Resident with Ongoing Jaw Pain
Penalty
Summary
The facility failed to ensure timely follow-up on a dental referral for a resident who had ongoing lower jaw pain. According to the facility's policy, residents are to be assisted in obtaining routine and emergency dental services, with referrals for dental procedures to be made within three days and documented if delayed. In this case, a resident with a history of bipolar disorder, left hemiplegia, major depressive disorder, and PTSD reported persistent pain in her lower jaw and had previously been seen by the facility dentist, who recommended an alveoloplasty. However, there was no documentation in the resident's medical record that the referral for this procedure, recommended in November, had been made or followed up on. The resident stated she had been waiting for months for a dental appointment and had not received any communication from the facility regarding the status of her referral, despite ongoing discomfort. Staff interviews confirmed that the social services department was responsible for coordinating dental care, but the facility was in the process of hiring new social services staff at the time. The nursing home administrator was unable to find any documentation that the dental referral had been initiated or completed for the resident as recommended by the dentist.
Failure to Provide Contracture Management and Comprehensive Care Planning
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for a resident with a left hand contracture. Despite the facility's policy requiring comprehensive care planning and implementation of specific interventions for residents with limited ROM, the resident's care plan did not address her left hand contracture or include any documented preventative measures or interventions. The occupational therapy plan had recommended the use of a palm guard for up to eight hours daily, but there was no evidence in the medical record that this recommendation was implemented. Observations over several days confirmed that the resident consistently did not have a palm guard, brace, or any other device on her contracted left hand. The resident herself reported that she had not received therapy services, braces, or preventative measures for her contracture. Staff interviews revealed a lack of awareness regarding the resident's contracture and the recommended interventions, with both the CNA and RN assigned to her care unaware of any current contracture management program or use of a palm guard. Further, the facility lacked a formal system to track and ensure the implementation of contracture management recommendations from therapy staff. The director of rehabilitation acknowledged the absence of a tracking system and was unsure if the occupational therapist's recommendations were being followed. The DON and NHA confirmed that the resident's contracture was not identified in the care plan and that the recommended palm protector was not part of the documented care, indicating a systemic failure to ensure appropriate contracture management.
Failure to Identify Root Cause and Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with a history of falls and significant cognitive and physical impairments. The resident, a 76-year-old with diagnoses including Parkinson's disease, vascular dementia, and major depressive disorder, required maximum assistance for transfers and had a documented history of falls. Despite multiple unwitnessed falls resulting in injuries such as skin tears and hematomas, the facility did not implement immediate or effective person-centered interventions following these incidents. Record review showed that after several falls, there was no evidence that the facility identified the root cause of the resident's falls or restlessness. The care plan and electronic medical record lacked documentation of new interventions or non-pharmacological strategies to address the resident's needs after each fall. Instead, the facility focused on medication changes, including the addition of Seroquel, without documented justification of behavioral symptoms such as restlessness or agitation prior to the falls. Staff interviews confirmed a lack of awareness regarding the resident's fall risk and absence of communication about necessary interventions. Additionally, the facility's interdisciplinary team did not document discussions or care plan changes with the resident or representative to minimize repeat falls, as required by policy. There was also no evidence that the facility investigated the circumstances of each fall to determine contributing factors. The lack of timely and appropriate interventions, as well as insufficient communication among staff, contributed to the ongoing risk of accidents for the resident.
Failure to Document and Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to implement its policies and procedures regarding influenza and pneumococcal vaccinations for two of five residents reviewed for immunizations. Specifically, there was a lack of documentation that the influenza vaccine was offered annually to both residents, and the pneumonia vaccine was not reoffered to one resident as required. Additionally, after one resident provided consent to receive the pneumococcal vaccine, there was no documentation that the vaccine was administered. For one resident, who had diagnoses including pneumonia, type 2 diabetes mellitus, COPD, and vascular dementia, the medical record showed that she declined both the influenza and pneumonia vaccines in 2022. However, there was no evidence in the electronic medical record that these vaccines were reoffered in subsequent years, as required by facility policy and CDC recommendations. The resident had severe cognitive impairment and required varying levels of assistance with daily activities. Another resident, with COPD and stage 4 chronic kidney disease and moderate cognitive impairment, initially declined the influenza vaccine but later indicated a desire to receive the pneumonia vaccine. Despite this consent, there was no documentation in the medical record that the pneumococcal vaccine was administered. Staff interviews confirmed that consents were obtained at admission and uploaded into the EMR, but failed to provide evidence that vaccines were reoffered annually or administered after consent was given.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding a resident's consistent refusal to take her prescribed anticoagulant medication, Eliquis, which was intended to manage her atrial fibrillation. The resident, who was cognitively intact and required assistance with daily activities, refused the medication on numerous occasions due to concerns about bleeding during dialysis. Despite being educated on the importance of the medication, the resident continued to refuse it. The nursing staff documented these refusals in the medication administration record (MAR) but did not consistently notify the physician about the refusals. The report highlights that the resident refused Eliquis 40 out of 62 times in October and 6 out of 11 times in November. Although the nursing staff was aware of the refusals and had a protocol to notify the physician after multiple refusals, this was not consistently followed. The facility's nurse practitioner was only informed in passing and was unaware of the frequency of the refusals. The assistant director of nursing confirmed that the protocol required notifying the provider after repeated refusals, which was not adhered to in this case.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, which constitutes a deficiency in ensuring resident safety. The incident occurred when one resident, who was cognitively intact, hit another resident, who had dementia and was unable to verbalize the incident, in the mouth and nose. This altercation was witnessed by a certified nurse aide (CNA), who reported that the aggressor had a tight grip on the victim's arm and struck him with a closed fist, resulting in a swollen and slightly bleeding lip. The facility's policy on abuse, neglect, and exploitation, which was revised in September 2022, mandates the protection of residents from harm and the implementation of measures to prevent abuse. Despite this policy, the facility did not adequately prevent the altercation or ensure the victim's safety, as evidenced by the lack of specific training for staff on handling resident behaviors and the absence of further documentation or monitoring of the victim following the incident. The victim, who had a history of behavioral disturbances and required substantial assistance with daily activities, was involved in previous altercations, highlighting a pattern of vulnerability. The aggressor, who had a history of behavioral issues such as verbal outbursts and refusing care, was placed on monitoring following the incident. However, staff interviews revealed a lack of specific training to address the behavioral needs of residents, which may have contributed to the failure to prevent the altercation. The facility's response to the incident included notifying relevant parties and assessing the victim, but the deficiency lies in the initial failure to protect the resident from abuse and ensure a safe environment.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADLs) to residents who were unable to perform them independently. Specifically, Resident #10 did not receive timely incontinence care and was not provided with the necessary encouragement and assistance during meals. Observations revealed that Resident #10 was left without encouragement or cueing during lunch and dinner, resulting in the resident not eating her meals. Additionally, the resident was not offered incontinence care for four hours, leading to redness and a soiled brief. Resident #10, who was over 65 years old, had diagnoses including anxiety, bipolar disorder, and dysphagia. The resident was cognitively impaired and required supervision and assistance with meals, as well as being dependent on staff for personal hygiene. Despite these needs, the care plan did not specify the frequency of incontinence care, and staff interviews confirmed the lack of encouragement and cueing during meals. Resident #16, aged 83, also experienced a lack of timely incontinence care. The resident, who had muscular dystrophy and was frequently incontinent, reported not being changed for over three hours during a night shift, resulting in sleeping in urine. The care plan for Resident #16 did not include approaches for managing incontinence, and a call light audit showed a delay in response time. Staff interviews indicated that call lights should be answered within 15 minutes, but this standard was not met for Resident #16.
Failure to Prevent Drug Diversion of Ativan
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate handling of controlled substances, specifically Ativan, for a resident. The deficiency was identified when a significant discrepancy in the narcotic count was discovered during a shift change. On the morning of November 1st, it was found that 44 Ativan tablets were missing from the resident's supply, which had been accounted for during the previous evening's shift change. The investigation revealed that the required narcotic count was not conducted at the 2:00 a.m. shift change, leading to the discovery of the missing medication at the 6:00 a.m. count. The facility's investigation involved reviewing the actions of the three licensed nurses who had access to the medication cart during the time frame in question. These nurses were subjected to drug testing, which returned negative results. The facility also reported the incident to the local police and the State Agency portal. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the narcotic count was not completed as required, contributing to the failure in preventing the drug diversion.
Inaccurate Documentation of Skin Assessments for Two Residents
Penalty
Summary
The facility failed to maintain accurately documented medical records for two residents, leading to deficiencies in the documentation of skin assessments. Resident #4, a 75-year-old with chronic obstructive pulmonary disease and other conditions, was observed with an open wound on her left foot. However, the nurse progress note inaccurately documented a rash on her right foot, and the provider note failed to mention the rash or treatment interventions. Additionally, there were no ordered interventions addressing the swelling or rash/wound, despite a physician's order to monitor the ankle swelling. Resident #12, a 79-year-old with a history of transient ischemic attack and other conditions, was admitted with an unstageable pressure injury. The admission skin assessment inaccurately documented the resident's skin as intact, despite indicating an open area on the coccyx. The progress notes did not document the pressure injury, although a wound physician later confirmed the presence of a sacral unstageable pressure injury. These inaccuracies in documentation were acknowledged by the facility's leadership team during interviews.
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 303 citations issued within 25 miles in the last 12 months — including the 4 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 Castle Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookside Inn | 3.9 mi | — | 14 | 1 |
| Center At Lincoln, Llc, The | 6.4 mi | — | 1 | 0 |
| Life Care Center Of Stonegate | 9 mi | — | 0 | 0 |
| Vi At Highlands Ranch Skilled Nursing | 10.2 mi | — | 0 | 0 |
| Parker Post Acute | 10.6 mi | — | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Silver Heights Skilled Nursing And Rehabilitation.
100% money-back within 48 hours.
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.