23 health deficiencies
Top issue: Resident Rights (7 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Denver, CO
2-star overall rating with 1-star inspections with abuse icon flag with $77,665 in total fines with 23 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3131 S Federal Blvd, Denver, CO
(303) 761-0260
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
Beds
110
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1984-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
RN hours / resident day
0.55
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.95
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
11,339
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.55
Baseline 83.15% · Performance 77.00% · Measure score 0.55 · Achievement 0 · Improvement 0.55
Adjusted total nurse staffing
2.88
Baseline 4.48 hours · Performance 3.90 hours · Measure score 2.88 · Achievement 2.88 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 6.17% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · 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 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 70 |
| Staff flu vaccination coverage | 58.82% |
42%
16.8 pts better
|
Numerator 50 · Denominator 85 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · 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 6 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
93.5%
3.3 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 95.2% · Q3 100.0% · Q4 100.0% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.4%
2.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
7.4%
5.3 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 3.3% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.0%
2.4 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.4% · Q3 0.0% · Q4 1.7% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
11.2%
2.7 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.1% · Q3 11.9% · Q4 9.7% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
20.6%
2 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 25.0% · Q3 25.6% · Q4 20.5% · 4Q avg 22.6% · 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 | 10.2% |
15.2%
5 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 8.2% · Q3 3.5% · Q4 10.1% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
14.6%
10.3 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.3% · Q3 1.7% · Q4 5.0% · 4Q avg 4.3% · 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 | 1.6% |
1.5%
0.1 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.7% · Q4 3.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
22.4%
1.1 pts better
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 13.4% · Q3 15.1% · Q4 26.8% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
3.7%
4.4 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.6% · Q3 9.4% · Q4 8.5% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.3% |
76.4%
0.1 pts worse
|
81.7%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 82.8% · 4Q avg 76.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.4% |
1.5%
5.9 pts worse
|
1.6%
5.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
75.6%
0.6 pts worse
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
Survey summary
Top issue: Resident Rights (7 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-02-02
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-02
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-02
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-22
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-30
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-07
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-07
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-01
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-01
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-01
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-01-12
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-18
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-02-02
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 2024-03-13
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 2024-03-18
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 2024-03-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-18
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-02-06
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-02-07
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-07
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 2024-02-07
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-13
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-02-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-09
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-09
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-03-13
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-18
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-03-18
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-02-02
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-02
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-11-11
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-11-15
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 2023-12-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-08
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 2023-09-08
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 2023-09-08
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
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 2023-09-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-14
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-04
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-14
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-14
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-10-14
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-11-23
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-10-14
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-14
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 2022-10-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-12-23
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-12-23
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-12-23
Health
Respond appropriately to all alleged violations.
Corrected 2019-12-23
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-12-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-12-23
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-01-06
Penalties and ownership
Fine · fine $28,912
Fine
Fine · fine $39,247
Fine
Payment Denial · denial start 2024-02-10 · 37 days
37 day denial
Fine · fine $9,506
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Contracted Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Denver, CO
3-star overall rating with 3-star inspections with $6,788 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Denver, CO
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Denver, CO
2-star overall rating with 1-star inspections with Special Focus status with $65,470 in total fines with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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