Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

THORNTON CARE CENTER

THORNTON, CO · 101 certified beds · Last Life Safety survey December 19, 2024

CMS Certification Number 065193 · first certified October 1984

Ownership

Operated by LONG PEAK OPERATING COMPANY · For profit - Limited Liability company

  • Ownership changed September 1, 2024 (change of ownership)from ARDENT HEALTH AND REHABILATION CENTER LLC
49
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
11
Tags cited more than once
Across separate surveys
27
Inspection & testing records
Of the citations on file

Position within CO

49 citations — more than 100% 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 10 citations; the earlier surveys in the window averaged 19.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: May 2026 to December 2026. This facility’s last Life Safety survey was December 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 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 three years in Maryland. How the window is measured

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Which alerts

8 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 ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

11 of the 49 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

8 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 49 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • 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.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

This facility49CO median16National median11
Citations on file over three years, compared
MeasureCitations
This facility49
Median facility in CO16
Median facility nationally11

Survey history

Citations at each Life Safety survey
282022-07112023-10102024-12
Citations at each Life Safety survey
Survey dateCitations
July 21, 202228
October 26, 202311
December 19, 202410

Most-cited tags

Most-cited tags at this facility
K-09183K-05213K-03453K-09113K-03243K-07123K-03633K-03533
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32024-12-19
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.32024-12-19
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32024-12-19
K-0911Meet requirements for the installation and maintenance of electrical systems.32024-12-19
K-0324Provide properly protected cooking facilities.32024-12-19
K-0712Have simulated fire drills held at unexpected times.32024-12-19
K-0363Install corridor and hallway doors that block smoke.32024-12-19
K-0353Inspect, test, and maintain automatic sprinkler systems.32024-12-19

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 16
  • Emergency Preparedness Deficiencies 11
  • Egress Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 6
  • Other 9
Citations by CMS category
CategoryCitations
Smoke Deficiencies16
Emergency Preparedness Deficiencies11
Egress Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies6
Miscellaneous Deficiencies5
Services Deficiencies4

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 19, 2024 — 10 citations

Citations issued on December 19, 2024
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (January 30, 2025)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (January 29, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (February 4, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (March 9, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (February 5, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 29, 2025)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has plan of correction (January 20, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (January 30, 2025)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (January 30, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 31, 2025)

October 26, 2023 — 11 citations

Citations issued on October 26, 2023
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (January 13, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (January 13, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (January 13, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (January 13, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 13, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 13, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (January 13, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (January 13, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (January 13, 2024)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (January 13, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 13, 2024)

July 21, 2022 — 28 citations

Citations issued on July 21, 2022
TagWhat the surveyor checksStatus
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (August 23, 2022)
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (August 23, 2022)
E-0018Establish procedures for tracking staff and patients during an emergency.Deficient, Provider has date of correction (August 23, 2022)
E-0023Establish policies and procedures for medical documentation.Deficient, Provider has date of correction (August 23, 2022)
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (August 23, 2022)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (August 23, 2022)
E-0032Provide primary/alternate means for communication.Deficient, Provider has date of correction (August 23, 2022)
E-0035Provide family notifications of emergency plan.Deficient, Provider has date of correction (August 23, 2022)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (August 23, 2022)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (August 23, 2022)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (August 23, 2022)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 13, 2022)
K-0222Add 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 (October 13, 2022)
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (October 13, 2022)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (October 13, 2022)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (October 13, 2022)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 13, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 13, 2022)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 13, 2022)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 13, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (October 13, 2022)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (October 13, 2022)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Waiver has been granted (September 19, 2022)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (October 13, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (October 13, 2022)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (October 13, 2022)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (October 13, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 13, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.