Cycle 1
Health 2024-07-16 · Fire 2024-07-16
16 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Denver, CO
City Scape Rehabilitation & Care Center LLC
2-star overall rating with 1-star inspections with abuse icon flag with $80,637 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3345 Forest St, Denver, CO
(303) 393-7600
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-10-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.72
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.69% |
8.2%
0.5 pts worse
|
Numerator 5 · Denominator 65 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
93.5%
8.4 pts worse
|
93.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 86.8% · Q3 80.8% · Q4 86.3% · 4Q avg 85.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
94.7%
0.3 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.9% · Q3 3.8% · Q4 2.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
7.4%
7.4 pts better
|
11.4%
11.4 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 who lose too much weight | 3.8% |
5.0%
1.2 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.5% · Q3 4.2% · Q4 2.2% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
11.2%
1.4 pts worse
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 12.0% · Q3 12.5% · Q4 8.7% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.8% |
20.6%
3.2 pts worse
|
16.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 20.0% · Q3 21.9% · Q4 27.3% · 4Q avg 23.8% · 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 | 9.0% |
15.2%
6.2 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.8% · Q3 10.4% · Q4 3.8% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
14.6%
0.9 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 24.5% · Q3 15.2% · Q4 2.3% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
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% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
22.4%
1.6 pts better
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 28.9% · Q3 26.0% · Q4 5.1% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
3.7%
1.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.4% · Q4 2.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.4% |
76.4%
9 pts worse
|
81.7%
14.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 67.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-02 · Fire 2023-03-02
11 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-07-16
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-15
F · Potential for more than minimal harm
2021-12-02
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-01-12
F · Potential for more than minimal harm
2021-12-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-30
D · Potential for more than minimal harm
2021-12-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-12-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-23
D · Potential for more than minimal harm
2021-12-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-12-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-01-12
Inspection history
Recent health citations
G · Actual harm
2025-07-01
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 2025-07-02
G · Actual harm
2025-07-01
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 2025-07-02
D · Potential for more than minimal harm
2025-05-01
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 2025-05-02
G · Actual harm
2024-07-16
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 2024-08-09
G · Actual harm
2024-07-16
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-16
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-16
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 2024-08-09
E · Potential for more than minimal harm
2024-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-16
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-08-09
C · Minimal harm
2024-07-16
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-08-09
E · Potential for more than minimal harm
2023-11-30
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-30
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 2024-01-10
G · Actual harm
2023-03-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-25
G · Actual harm
2023-03-02
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 2023-03-25
F · Potential for more than minimal harm
2023-03-02
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-03-25
F · Potential for more than minimal harm
2023-03-02
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 2023-03-24
E · Potential for more than minimal harm
2023-03-02
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 2023-03-25
E · Potential for more than minimal harm
2023-03-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-25
D · Potential for more than minimal harm
2023-03-02
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 2023-03-25
D · Potential for more than minimal harm
2023-03-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-25
D · Potential for more than minimal harm
2023-03-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-03-25
D · Potential for more than minimal harm
2023-03-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-25
D · Potential for more than minimal harm
2023-03-02
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-03-25
E · Potential for more than minimal harm
2021-12-02
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 2021-12-31
E · Potential for more than minimal harm
2021-12-02
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 2021-12-31
E · Potential for more than minimal harm
2021-12-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-12-31
E · Potential for more than minimal harm
2021-12-02
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 2021-12-31
D · Potential for more than minimal harm
2021-12-02
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2021-12-31
D · Potential for more than minimal harm
2021-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-31
D · Potential for more than minimal harm
2021-12-02
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2021-12-31
Penalties and ownership
What sits behind the stars
$60,270
2025-07-01
Fine
Fine · fine $60,270
Fine
$20,367
2024-07-16
Fine
Fine · fine $20,367
Fine
Ownership
Nearby options
Other facilities in reach
#1
City Park Healthcare And Rehabilitation Center
Denver, CO
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
#2
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
#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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