9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Denver, CO
2-star overall rating with 1-star inspections with $66,307 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
290 S Monaco Pkwy, Denver, CO
(303) 355-2525
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
160
Certified beds
Average residents
143
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1988-08-01
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
0.47
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.01
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.84
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
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
2.91
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
5,811
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.91
Performance 19.15% · Measure score 4.91 · Achievement 4.91 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.33
Performance 6.24% · Measure score 5.33 · Achievement 5.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.73
Baseline 58.59% · Performance 48.42% · Measure score 3.73 · Achievement 3.73 · Improvement 2.51
Adjusted total nurse staffing
0
Baseline 3.44 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.74% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 45 · Observed rate 13.33% · Lower 95% interval 7.21% |
| Discharge to community | 37.79% |
50.57%
12.8 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 25% · Lower 95% interval 25.35% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 66 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 75.51% |
53.69%
21.8 pts better
|
Numerator 37 · Denominator 49 |
| Discharge mobility score | 48.98% |
50.94%
2 pts worse
|
Numerator 24 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 66 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | 90.41% |
42%
48.4 pts better
|
Numerator 198 · Denominator 219 |
| Discharge function score | 73.47% |
56.45%
17 pts better
|
Numerator 36 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 79.41% |
25.2%
54.2 pts better
|
Numerator 27 · Denominator 34 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 2.1 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.2 · Expected 2.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
93.5%
5.7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.7%
3.8 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.4%
3 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.6% |
7.4%
5.2 pts worse
|
11.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.3% · Q3 14.9% · Q4 14.8% · 4Q avg 12.6% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.0%
4.3 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.9% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
11.2%
1.6 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 8.4% · Q3 7.7% · Q4 9.8% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
20.6%
6.7 pts better
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 16.4% · Q3 13.7% · Q4 13.8% · 4Q avg 13.9% · 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 | 5.6% |
15.2%
9.6 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.3% · Q3 2.4% · Q4 9.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.9% |
14.6%
11.7 pts better
|
14.9%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 6.9% · Q4 2.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.8%
0.5 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
22.4%
0.7 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 38.3% · Q3 15.6% · Q4 18.7% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
3.7%
2.1 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.9% · Q3 2.9% · Q4 5.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
76.4%
21.2 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 94.0% · Q3 98.8% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
12.8%
0.2 pts better
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 17.1% · Expected 15.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
75.6%
14.8 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
20.3%
0.9 pts worse
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 29.3% · Expected 32.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-26
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-03
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-27
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-02
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-02-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-25
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-01-27
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-07
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-06
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-06
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-12-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-15
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2021-12-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-06
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2021-12-06
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-12-06
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 2021-12-06
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-06
Inspection history
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-12-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-06
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-06
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-09-06
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-06
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 2024-09-06
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-09-06
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-09-06
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-06
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-09-06
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-06
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2024-09-06
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-06
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-30
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-30
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 2024-03-30
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-30
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-30
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-30
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-11
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-17
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2023-03-24
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-03-24
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-02-24
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-02-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-24
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-24
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-09-30
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-09-30
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-17
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-09-30
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-09-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-09-30
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 2021-09-30
Penalties and ownership
Fine · fine $53,372
Fine
Payment Denial · denial start 2024-08-27 · 10 days
10 day denial
Fine · fine $12,935
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Corporate Officer · 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
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Denver, CO
5-star overall rating with 3-star inspections with $17,160 in total fines with 3 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
Denver, CO
3-star overall rating with 2-star inspections with abuse icon flag with $845 in total fines with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Denver, CO
2-star overall rating with 1-star inspections with $17,933 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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