Cycle 1
Health 2024-01-23 · Fire 2024-01-23
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Denver, CO
Sloan's Lake Rehabilitation Center
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1601 Lowell Blvd, Denver, CO
(303) 534-2211
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2013-01-30
CMS approved date
Coverage
Medicare
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
0.95
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.24
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.98
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.97
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,381
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0122
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.77
Baseline 19.05% · Performance 17.83% · Measure score 7.77 · Achievement 7.77 · Improvement 5.52
Healthcare-associated infections
5.31
Baseline 3.77% · Performance 6.25% · Measure score 5.31 · Achievement 5.31 · Improvement 0
Total nurse turnover
5.79
Baseline 53.57% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 4.23
Adjusted total nurse staffing
3.95
Baseline 3.87 hours · Performance 4.20 hours · Measure score 3.95 · Achievement 3.95 · Improvement 1.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.41% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 6.57% · Lower 95% interval 6.09% |
| Discharge to community | 70.2% |
50.57%
19.6 pts better
|
Better than the National Rate · Eligible stays 132 · Observed rate 67.42% · Lower 95% interval 61.04% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.99% |
95.27%
3.7 pts better
|
Numerator 98 · Denominator 99 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 99 |
| Discharge self-care score | 58.97% |
53.69%
5.3 pts better
|
Numerator 46 · Denominator 78 |
| Discharge mobility score | 58.97% |
50.94%
8 pts better
|
Numerator 46 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 99 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.25% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 3.9% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 93.43% |
42%
51.4 pts better
|
Numerator 128 · Denominator 137 |
| Discharge function score | 58.97% |
56.45%
2.5 pts better
|
Numerator 46 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 64 · Denominator 64 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 47.17% |
25.2%
22 pts better
|
Numerator 25 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
76.4%
23.1 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.3% · Q3 99.0% · Q4 99.8% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
12.8%
6.5 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 6.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
75.6%
9.6 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.4% |
20.3%
8.9 pts better
|
23.9%
12.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 10.0% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-07-15 · Fire 2021-07-15
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-26
E · Potential for more than minimal harm
2022-10-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-10-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-10
F · Potential for more than minimal harm
2021-07-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-08-26
F · Potential for more than minimal harm
2021-07-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-21
F · Potential for more than minimal harm
2021-07-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-21
F · Potential for more than minimal harm
2021-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-21
D · Potential for more than minimal harm
2021-07-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-08-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-01-23
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 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-09
E · Potential for more than minimal harm
2022-10-13
F578 · Resident Rights Deficiencies
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 2022-11-11
E · Potential for more than minimal harm
2022-10-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-11
J · Immediate jeopardy
2021-07-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-07-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-07-15
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 2021-07-23
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Dunyon, David
Corporate Officer · Individual
Horton, Christopher
Operational/Managerial Control · Individual
Jorgensen, David
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Director · Individual
Kare Technologies LLC
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Juniper Village - The Spearly Center
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
#2
Edgewater Health and Rehabilitation
Lakewood, CO
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Cedars Healthcare Center
Lakewood, CO
1-star overall rating with 1-star inspections with $31,663 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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