Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SOUTH PLATTE REHABILITATION AND NURSING LLC
BRUSH, CO · 78 certified beds · Last Life Safety survey October 8, 2024
CMS Certification Number 065170 · first certified October 1982
Ownership
Operated by THE CHARLY BELLO FAMILY, THE MAZE FAMILY, THE SWAIN FAMILY, & WALTER MYERS · For profit - Limited Liability company
- Ownership changed September 1, 2024 (change of ownership)from SOUTH PLATTE HEALTH AND REHABILITATION CENTER LLC
Position within CO
29 citations — more than 86% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys on file averaged 11. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (April 2026 to November 2026). Most CO facilities have been surveyed by January 2027. This facility’s last Life Safety survey was October 2024. Facilities in CO are typically surveyed 18–25 months after the last one (median 21), measured over 187 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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9 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 26, 2019 | 8 |
| May 18, 2023 | 14 |
| October 8, 2024 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-10-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-05-18 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2023-05-18 |
| K-0271 | Have exits that are accessible at all times. | 2 | 2024-10-08 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2023-05-18 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-10-08 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-10-08 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-10-08 |
What the citations cover
- Smoke Deficiencies 10
- Egress Deficiencies 7
- Miscellaneous Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Egress Deficiencies | 7 |
| Miscellaneous Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 4 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 8, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (October 30, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 30, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (October 29, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 30, 2024) |
| K-0751 | Have restrictions on the use of flammable curtains. | Deficient, Provider has date of correction (October 30, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (October 30, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 30, 2024) |
May 18, 2023 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (June 28, 2023) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 27, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 20, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (December 31, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 10, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 27, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (July 10, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 10, 2023) |
September 26, 2019 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 19, 2019) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (November 19, 2019) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 19, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 19, 2019) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 19, 2019) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 19, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 19, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 19, 2019) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.