Cycle 1
Health 2024-03-20 · Fire 2024-03-20
21 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Wheat Ridge, CO
Mountain Vista Health Center
2-star overall rating with 1-star inspections with abuse icon flag with $39,227 in total fines with 21 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
4800 Tabor St, Wheat Ridge, CO
(303) 421-4161
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
168
Certified beds
Average residents
82
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
American Baptist Homes Of The Midwest
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing
LPN hours / resident day
1.07
Licensed practical nurse staffing
Aide hours / resident day
2.39
Nurse aide staffing
Weekend hours
3.87
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
64%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
93.5%
5.6 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.7%
4.3 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.4%
0.8 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
7.4%
0.3 pts better
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.0%
1.5 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.7% |
11.2%
6.5 pts better
|
19.6%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
20.6%
0.7 pts better
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.4% |
15.2%
12.2 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
14.6%
11.5 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.5%
0.6 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
22.4%
7.3 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
3.7%
1.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
76.4%
18.3 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
75.6%
18.7 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-08 · Fire 2022-12-08
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-09-13 · Fire 2021-09-13
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-20
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-20
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 2024-05-19
F · Potential for more than minimal harm
2024-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-19
E · Potential for more than minimal harm
2024-03-20
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 2024-05-19
E · Potential for more than minimal harm
2024-03-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-19
D · Potential for more than minimal harm
2024-03-20
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 2024-05-19
D · Potential for more than minimal harm
2024-03-20
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-05-19
E · Potential for more than minimal harm
2022-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-30
E · Potential for more than minimal harm
2022-12-08
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-27
D · Potential for more than minimal harm
2022-12-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-25
F · Potential for more than minimal harm
2021-09-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-10-16
F · Potential for more than minimal harm
2021-09-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-10-16
F · Potential for more than minimal harm
2021-09-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-12
F · Potential for more than minimal harm
2021-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-26
E · Potential for more than minimal harm
2021-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-05
D · Potential for more than minimal harm
2021-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-09
D · Potential for more than minimal harm
2021-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-10-28
D · Potential for more than minimal harm
2021-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-10
D · Potential for more than minimal harm
2021-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-11-09
D · Potential for more than minimal harm
2021-09-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-11-11
D · Potential for more than minimal harm
2021-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-12
D · Potential for more than minimal harm
2021-09-13
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2021-11-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-02
E · Potential for more than minimal harm
2025-06-11
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 2025-07-14
F · Potential for more than minimal harm
2025-03-24
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-24
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 2025-04-30
D · Potential for more than minimal harm
2025-03-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-24
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 2025-04-30
D · Potential for more than minimal harm
2025-02-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-21
G · Actual harm
2024-11-20
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 2024-07-31
G · Actual harm
2024-03-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-20
F585 · Resident Rights Deficiencies
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 2024-04-17
E · Potential for more than minimal harm
2024-03-20
F726 · Nursing and Physician Services Deficiencies
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 2024-04-17
E · Potential for more than minimal harm
2024-03-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-20
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 2024-04-17
D · Potential for more than minimal harm
2024-03-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-20
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 2024-04-17
D · Potential for more than minimal harm
2024-03-20
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-20
F688 · Quality of Life and Care Deficiencies
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 2024-04-17
D · Potential for more than minimal harm
2024-03-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-20
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-17
G · Actual harm
2023-11-01
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 2023-11-22
E · Potential for more than minimal harm
2023-09-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-30
D · Potential for more than minimal harm
2022-12-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-08
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 2023-01-16
D · Potential for more than minimal harm
2022-12-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-16
E · Potential for more than minimal harm
2021-09-13
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 2021-10-13
E · Potential for more than minimal harm
2021-09-13
F688 · Quality of Life and Care Deficiencies
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 2021-10-13
E · Potential for more than minimal harm
2021-09-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-10-13
E · Potential for more than minimal harm
2021-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-12
D · Potential for more than minimal harm
2021-09-13
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 2021-10-13
D · Potential for more than minimal harm
2021-09-13
F726 · Nursing and Physician Services Deficiencies
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 2021-10-13
D · Potential for more than minimal harm
2021-09-13
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 2021-10-13
Penalties and ownership
What sits behind the stars
$7,718
2024-11-20
Fine
Fine · fine $7,718
Fine
$23,319
2024-03-20
Fine
Fine · fine $23,319
Fine
$8,190
2023-11-01
Fine
Fine · fine $8,190
Fine
Ownership
Allen, Ryan
Corporate Director · Individual
Baptist Home Association Of The Rocky Mountains Inc
Operational/Managerial Control · Organization
Blatnik, Andrea
W-2 Managing Employee · Individual
Davidson, Roger
Corporate Director · Individual
Ford, Ashley
Corporate Director · Individual
Hanson, Phillip
Corporate Director · Individual
Johnson, Dorothy
Corporate Director · Individual
Johnson, James
Corporate Director · Individual
Johnson, Lars
Corporate Officer · Individual
Killian, George
Corporate Director · Individual
Neiman, Ruth
Corporate Officer · Individual
Peters, Marshall
Corporate Director · Individual
Van Der Beek, Bruce
Corporate Officer · Individual
Vanostram, Steven
Corporate Director · Individual
Vaughn-Gray, Stephanie
Corporate Officer · Individual
Wagoner Ford, Anne
Corporate Director · Individual
Whitaker, Bruce
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Lakewood Villa
Lakewood, CO
3-star overall rating with 2-star inspections with abuse icon flag with $40,006 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Ahc Of Lakewood, LLC
Lakewood, CO
5-star overall rating with 4-star inspections with $72,634 in total fines with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Lakeside Post Acute
Wheat Ridge, CO
2-star overall rating with 2-star inspections with abuse icon flag with $14,058 in total fines with 10 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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