2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Denver, CO
0-star overall rating with 0-star inspections with Special Focus status with $273,972 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2205 W 29th Ave, Denver, CO
(303) 458-1112
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Beds
135
Certified beds
Average residents
124
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Juniper Communities
Operator or chain grouping
Approved since
1994-04-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.38
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.53
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.27
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
0.88
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
9,164
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
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
4.62
Baseline 45.20% · Performance 44.78% · Measure score 4.62 · Achievement 4.62 · Improvement 0
Adjusted total nurse staffing
0.29
Baseline 2.34 hours · Performance 2.62 hours · Measure score 0.29 · Achievement 0 · Improvement 0.29
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 5 · 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 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| 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 | 12.59% |
8.2%
4.4 pts better
|
Numerator 18 · Denominator 143 |
| Staff flu vaccination coverage | 98.01% |
42%
56 pts better
|
Numerator 148 · Denominator 151 |
| 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 2 · 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
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
93.5%
2.9 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 96.5% · Q3 98.2% · Q4 93.5% · 4Q avg 96.4% |
| 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 | 4.5% |
3.4%
1.1 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.5% · Q3 5.3% · Q4 5.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
7.4%
6.6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 0.0% · Q4 0.9% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.0%
0.8 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.0% · Q3 5.6% · Q4 5.4% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.9% |
11.2%
1.3 pts better
|
19.6%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 13.7% · Q3 11.2% · Q4 4.4% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 62.1% |
20.6%
41.5 pts worse
|
16.7%
45.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.5% · Q2 64.3% · Q3 60.0% · Q4 61.7% · 4Q avg 62.1% · 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 | 8.9% |
15.2%
6.3 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.2% · Q3 7.5% · Q4 11.8% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
14.6%
0.6 pts better
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 13.3% · Q3 11.7% · Q4 12.5% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.8%
1.3 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.9% · Q3 2.5% · Q4 1.5% · 4Q avg 2.1% · 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 0.0% · Q2 0.0% · Q3 0.9% · 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 | 17.7% |
22.4%
4.7 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 16.1% · Q3 13.5% · Q4 21.4% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
3.7%
0.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.2% · Q3 4.3% · Q4 2.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.4% |
76.4%
29 pts worse
|
81.7%
34.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 45.8% · 4Q avg 47.4% |
| 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: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
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 2026-02-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-31
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 2025-04-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-21
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-25
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-04-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-06
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-05-24
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-13
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 2024-08-20
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-06
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-16
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-07
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-07
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-07
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-07
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-07
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-07
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-06
Fire Safety
Provide large enough exits.
Corrected 2024-06-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-06
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2024-06-06
Inspection history
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 2025-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-26
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-26
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-26
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-26
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-04-26
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 2025-04-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-26
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 2025-04-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-12
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-01-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-24
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2024-05-24
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-05-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-24
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-24
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-24
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-05-24
Health
Dispose of garbage and refuse properly.
Corrected 2024-05-24
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-24
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 2024-05-24
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-24
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-24
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 2024-05-24
Health
Post nurse staffing information every day.
Corrected 2024-05-24
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 2024-01-10
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-15
Penalties and ownership
Fine · fine $10,953
Fine
Fine · fine $114,111
Fine
Fine · fine $14,050
Fine
Fine · fine $42,965
Fine
Payment Denial · denial start 2024-07-02 · 76 days
76 day denial
Fine · fine $66,256
Fine
Fine · fine $19,286
Fine
Fine · fine $6,351
Fine
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
Limited Partnership Interest · Organization
Operational/Managerial Control · Organization
Limited Partnership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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