Cycle 1
Health 2023-11-13 · Fire 2023-11-13
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Denver, CO
South Valley Post Acute Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
4450 E Jewell Ave, Denver, CO
(303) 757-7438
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
106
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1986-03-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
2.06
Nurse aide staffing
Weekend hours
2.98
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
93.5%
1 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
94.7%
2.4 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.4%
1.2 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 31.6% |
7.4%
24.2 pts worse
|
11.4%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.0%
1.8 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
11.2%
2.3 pts worse
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
20.6%
9.8 pts better
|
16.7%
5.9 pts better
|
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 | 14.2% |
15.2%
1 pts better
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
14.6%
3.9 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.8%
0.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.5%
1.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
22.4%
2 pts better
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
3.7%
0.9 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
76.4%
7.8 pts better
|
81.7%
2.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
12.8%
3.3 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.2% |
75.6%
0.6 pts better
|
79.7%
3.5 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
20.3%
1.9 pts worse
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-08 · Fire 2022-09-08
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2020-02-27 · Fire 2020-02-27
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-18
F · Potential for more than minimal harm
2023-11-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-18
F · Potential for more than minimal harm
2023-11-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-12-18
F · Potential for more than minimal harm
2022-09-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-07
F · Potential for more than minimal harm
2022-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-31
F · Potential for more than minimal harm
2022-09-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-02
F · Potential for more than minimal harm
2022-09-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-02
F · Potential for more than minimal harm
2022-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-28
F · Potential for more than minimal harm
2022-09-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-09-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-09-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-07
E · Potential for more than minimal harm
2022-09-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-09-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-02
F · Potential for more than minimal harm
2020-02-27
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2020-04-23
F · Potential for more than minimal harm
2020-02-27
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2020-04-23
F · Potential for more than minimal harm
2020-02-27
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-04-23
E · Potential for more than minimal harm
2020-02-27
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2020-06-02
D · Potential for more than minimal harm
2020-02-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-06-02
D · Potential for more than minimal harm
2020-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-06-02
D · Potential for more than minimal harm
2020-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-07-13
D · Potential for more than minimal harm
2020-02-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2020-07-13
D · Potential for more than minimal harm
2020-02-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-06-02
D · Potential for more than minimal harm
2020-02-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2020-06-02
D · Potential for more than minimal harm
2020-02-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-06-02
D · Potential for more than minimal harm
2020-02-27
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2020-06-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-29
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.
Not marked corrected
D · Potential for more than minimal harm
2024-05-16
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 2024-06-15
D · Potential for more than minimal harm
2023-11-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-29
D · Potential for more than minimal harm
2022-09-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-10-02
D · Potential for more than minimal harm
2022-09-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-02
G · Actual harm
2020-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-23
G · Actual harm
2020-02-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-04-23
G · Actual harm
2020-02-27
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 2020-04-23
F · Potential for more than minimal harm
2020-02-27
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 2020-04-23
F · Potential for more than minimal harm
2020-02-27
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 2020-04-23
F · Potential for more than minimal harm
2020-02-27
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 2020-04-23
E · Potential for more than minimal harm
2020-02-27
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 2020-04-23
E · Potential for more than minimal harm
2020-02-27
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-02-27
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-02-27
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 2020-04-23
D · Potential for more than minimal harm
2020-02-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-02-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-02-27
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 2020-04-23
D · Potential for more than minimal harm
2020-02-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-04-23
Penalties and ownership
What sits behind the stars
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Graham, Joseph
Corporate Officer · Individual
Horton, Christopher
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
Wilson, Hunter
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Rowan Community, Inc
Denver, CO
3-star overall rating with 2-star inspections with $4,622 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Amberwood Post Acute
Denver, CO
2-star overall rating with 2-star inspections with $9,636 in total fines with 17 recent health deficiencies
#3
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
Jump out