Cycle 1
Health 2025-08-21 · Fire 2025-08-21
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Denver, CO
Holly Heights Care And Rehabilitation
2-star overall rating with 2-star inspections with $15,548 in total fines with 14 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
6000 E Iliff Ave, Denver, CO
(303) 757-5441
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
133
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1974-10-01
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
0.58
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.52
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.80
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.45
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.51
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
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.27
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 23 · 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 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90% |
95.27%
5.3 pts worse
|
Numerator 27 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 52.17% |
53.69%
1.5 pts worse
|
Numerator 12 · Denominator 23 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 10 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 18.92% |
8.2%
10.7 pts better
|
Numerator 21 · Denominator 111 |
| Staff flu vaccination coverage | 87.57% |
42%
45.6 pts better
|
Numerator 162 · Denominator 185 |
| Discharge function score | 47.83% |
56.45%
8.6 pts worse
|
Numerator 11 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.3 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
93.5%
0.2 pts worse
|
93.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 91.5% · Q3 86.2% · Q4 95.3% · 4Q avg 93.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.9% |
94.7%
8.8 pts worse
|
95.5%
9.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.4%
0.1 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.7% · Q3 2.5% · Q4 1.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.5% |
7.4%
2.1 pts worse
|
11.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.3% · Q3 10.8% · Q4 16.2% · 4Q avg 9.5% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.0%
0.7 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 8.0% · Q3 5.3% · Q4 7.7% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
11.2%
1.4 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.3% · Q3 6.6% · Q4 13.8% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
20.6%
0.6 pts worse
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 22.4% · Q3 24.5% · Q4 20.0% · 4Q avg 21.2% · 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 | 10.0% |
15.2%
5.2 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.0% · Q3 14.9% · Q4 12.3% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
14.6%
8.8 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 9.9% · Q3 4.2% · Q4 6.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.8%
1.2 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 2.2% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 33.8% |
22.4%
11.4 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q2 43.9% · Q3 28.6% · Q4 22.5% · 4Q avg 33.8% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
3.7%
2.4 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.3% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.8% |
76.4%
12.6 pts worse
|
81.7%
17.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 45.0% · Q3 55.9% · Q4 81.8% · 4Q avg 63.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
12.8%
1.7 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 15.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.1% |
75.6%
44.5 pts worse
|
79.7%
48.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.9% |
20.3%
5.4 pts better
|
23.9%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 15.0% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-09 · Fire 2024-01-09
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-08-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-08-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-10-18
F · Potential for more than minimal harm
2025-08-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-04-18
F · Potential for more than minimal harm
2025-08-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-04-18
F · Potential for more than minimal harm
2025-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-07
E · Potential for more than minimal harm
2025-08-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-08-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-10-18
E · Potential for more than minimal harm
2025-08-21
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 2025-10-18
E · Potential for more than minimal harm
2025-08-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-18
D · Potential for more than minimal harm
2025-08-21
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 2025-10-18
D · Potential for more than minimal harm
2025-08-21
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-10-18
D · Potential for more than minimal harm
2025-08-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-18
F · Potential for more than minimal harm
2024-01-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-02-08
F · Potential for more than minimal harm
2024-01-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-30
F · Potential for more than minimal harm
2024-01-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-04
E · Potential for more than minimal harm
2022-09-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-09-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-09-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2026-02-19
E · Potential for more than minimal harm
2025-12-04
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-08-21
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 2025-09-19
E · Potential for more than minimal harm
2025-08-21
F809 · Nutrition and Dietary Deficiencies
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 2025-09-19
E · Potential for more than minimal harm
2025-08-21
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 2025-09-19
E · Potential for more than minimal harm
2025-08-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-21
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-21
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-21
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 2025-09-19
D · Potential for more than minimal harm
2025-08-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-21
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 2025-09-19
D · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-19
J · Immediate jeopardy
2025-06-11
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 2025-04-10
D · Potential for more than minimal harm
2024-10-28
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 2024-11-17
E · Potential for more than minimal harm
2024-06-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-21
F · Potential for more than minimal harm
2024-01-09
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 2024-02-14
F · Potential for more than minimal harm
2024-01-09
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-09
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 2024-02-10
D · Potential for more than minimal harm
2024-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-09
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-02-05
G · Actual harm
2023-06-15
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 2023-06-17
G · Actual harm
2022-09-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-07
Penalties and ownership
What sits behind the stars
$9,113
2025-06-11
Fine
Fine · fine $9,113
Fine
$6,435
2023-06-15
Fine
Fine · fine $6,435
Fine
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Abbott, Swati
Corporate Director · Individual
Agwunobi, John
Corporate Director · Individual
Blouin, Ann
Corporate Director · Individual
Burnam, Soon
Corporate Officer · Individual
Burton, Spencer
Corporate Officer · Individual
Christensen, Christopher
Corporate Director · Individual
Graham, Joseph
Corporate Officer · Individual
Hughes, Heath
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Officer · Individual
Parkinson, Mark
Corporate Director · Individual
Port, Barry
Corporate Director · Individual
Port, Barry
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Shaw, Daren
Corporate Director · Individual
Smith, Barry
Corporate Director · Individual
Snapper, Suzanne
Corporate Director · Individual
Snapper, Suzanne
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Highline Post Acute
Denver, CO
1-star overall rating with 1-star inspections with $57,059 in total fines with 15 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#2
Brookshire Post Acute
Denver, CO
2-star overall rating with 1-star inspections with abuse icon flag with $75,713 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Amberwood Post Acute
Denver, CO
2-star overall rating with 2-star inspections with $9,636 in total fines with 17 recent health deficiencies
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