Cycle 1
Health 2023-10-12 · Fire 2023-10-12
19 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Denver, CO
City Park Healthcare And Rehabilitation Center
2-star overall rating with 2-star inspections with abuse icon flag with $12,735 in total fines with 19 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1667 Saint Paul St, Denver, CO
(303) 399-2040
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1980-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.97
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 8.82% · Lower 95% interval 6.79% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.61 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 32 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 81.82% |
53.69%
28.1 pts better
|
Numerator 18 · Denominator 22 |
| Discharge mobility score | 77.27% |
50.94%
26.3 pts better
|
Numerator 17 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.56% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 128 |
| Staff flu vaccination coverage | 89.6% |
42%
47.6 pts better
|
Numerator 155 · Denominator 173 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 16 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 39.13% |
25.2%
13.9 pts better
|
Numerator 9 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.7
1.4 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
93.5%
4 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 82.7% · Q3 85.7% · Q4 99.1% · 4Q avg 89.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
94.7%
2.5 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.4%
1.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.8% · Q3 1.0% · Q4 0.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.5% |
7.4%
15.1 pts worse
|
11.4%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 25.7% · Q3 55.0% · Q4 6.7% · 4Q avg 22.5% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.0%
0.3 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 8.8% · Q3 2.9% · Q4 2.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.2% |
11.2%
9 pts better
|
19.6%
17.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.9% · Q3 1.0% · Q4 0.9% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
20.6%
3.9 pts better
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 12.7% · Q3 15.6% · Q4 21.5% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.5% |
15.2%
0.3 pts worse
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 31.3% · Q3 6.7% · Q4 1.9% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
14.6%
1.1 pts worse
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 28.7% · Q3 6.5% · Q4 2.0% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.8%
0.3 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.5%
1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.4% |
22.4%
10 pts better
|
19.8%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 19.8% · Q3 3.9% · Q4 6.5% · 4Q avg 12.4% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
3.7%
0.1 pts worse
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.6% · Q3 5.3% · Q4 2.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
76.4%
11.8 pts better
|
81.7%
6.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.3% · Q2 86.8% · Q3 92.0% · Q4 95.8% · 4Q avg 88.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.5% |
12.8%
9.3 pts better
|
12.0%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 3.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.9% |
75.6%
10.3 pts better
|
79.7%
6.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
20.3%
1 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 18.5% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-14 · Fire 2022-07-14
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-04-15 · Fire 2021-04-15
26 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-10-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-10-12
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-12-18
F · Potential for more than minimal harm
2022-07-14
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-08-18
F · Potential for more than minimal harm
2022-07-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-26
F · Potential for more than minimal harm
2022-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-29
F · Potential for more than minimal harm
2022-07-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-18
F · Potential for more than minimal harm
2022-07-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-18
F · Potential for more than minimal harm
2022-07-14
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-08-18
F · Potential for more than minimal harm
2021-04-15
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-05-14
F · Potential for more than minimal harm
2021-04-15
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-05-14
F · Potential for more than minimal harm
2021-04-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-04-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-05-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-11
G · Actual harm
2025-10-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-24
D · Potential for more than minimal harm
2024-03-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-01-11
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-23
F · Potential for more than minimal harm
2023-10-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-11
E · Potential for more than minimal harm
2023-10-12
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-11
E · Potential for more than minimal harm
2023-10-12
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-11-11
E · Potential for more than minimal harm
2023-10-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-10-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-10-12
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-10-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-12
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-11-11
F · Potential for more than minimal harm
2023-06-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-01
F · Potential for more than minimal harm
2022-07-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-12
K · Immediate jeopardy
2021-04-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-05-14
F · Potential for more than minimal harm
2021-04-15
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-05-14
F · Potential for more than minimal harm
2021-04-15
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-05-14
F · Potential for more than minimal harm
2021-04-15
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-05-14
F · Potential for more than minimal harm
2021-04-15
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-30
D · Potential for more than minimal harm
2021-04-15
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-15
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-15
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-15
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-05-14
Penalties and ownership
What sits behind the stars
$12,735
2025-10-30
Fine
Fine · fine $12,735
Fine
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Gahm, Gregory
Operational/Managerial Control · Individual
Graham, Joseph
Corporate Officer · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Onshift Inc
Operational/Managerial Control · Organization
Rocky Mountain Respiratory Resource
Operational/Managerial Control · Organization
Sato, Ami
Corporate Officer · Individual
Wondmagegn, Fasil
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Briarwood Health Care Center
Denver, CO
4-star overall rating with 3-star inspections with $47,867 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Health Center At Franklin Park
Denver, CO
4-star overall rating with 3-star inspections with $10,082 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Denver North Care Center
Denver, CO
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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