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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D25 | E10 | F25 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jun 17, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 5, 2024 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Dec 5, 2024 | Health | Health Complaint, Health Standard | 5 | Potential harm | — | Open → |
| Mar 19, 2024 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Jun 29, 2023 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Jun 29, 2023 | Health | Health Standard | 14 | Potential harm | — | Open → |
| Aug 29, 2019 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Aug 29, 2019 | Health | Health Standard | 4 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D25 | E10 | F25 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jun 17, 2025 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 7, 2025 | Complaint |
| Jun 17, 2025 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 7, 2025 | Complaint |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
347 facilities in 17 states. CMS chain ID 507.
Chain average overall rating (CMS): 3.3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Barry Port | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Sep 5, 2025 |
| Christopher Horton | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Mar 1, 2023 |
| Dontre Mcdonald | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Mar 1, 2023 |
| Christopher Horton | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Dontre Mcdonald | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| David Jorgensen | Individual |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| City Park Healthcare and Rehabilitation Center 1667 Saint Paul St, Denver, CO 80206 CCN 065009Abuse icon | 125 | Jan 15, 2026 | 491 harm | $8,278 | |
| Englewood Post Acute and Rehabilitation 3575 S Washington St, Englewood, CO 80113 CCN 065077 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Oakwood Care and Rehabilitation 5301 W 1st Ave, Lakewood, CO 80226 CCN 065248Abuse icon | 0.9 km | 170 | Feb 26, 2026 | 1181 IJ9 harm2 open | $106k | |
| Sierra Post Acute 1432 Depew St, Lakewood, CO 80214 CCN 065272Abuse icon | 2.3 km | 102 | Jul 13, 2026 | 411 IJ5 harm | $55k | |
| Cedars Healthcare Center 1599 Ingalls St, Lakewood, CO 80214 CCN 065202 | 2.6 km | 130 | Jun 11, 2026 | 582 IJ2 open | $16k | |
| Edgewater Health and Rehabilitation 1655 Eaton St, Lakewood, CO 80214 CCN 065171 | 2.7 km | 67 | Aug 27, 2025 | 291 harm | — | |
| Cambridge Care Center 1685 Eaton St, Lakewood, CO 80214 CCN 065296Abuse icon | 2.8 km | 110 | Jun 11, 2026 | 391 harm | $8,151 | |
| Harmony Pointe Care Center 1655 Yarrow St, Lakewood, CO 80214 CCN 065298 | 3.2 km | 125 | Sep 26, 2024 | 573 harm | — | |
| Villa Manor Care Center 7950 W Mississippi Ave, Lakewood, CO 80226 CCN 065092 | 3.6 km | 110 | Mar 26, 2026 | 50 | — | |
| Western Hills Health Care Center 1625 Carr St, Lakewood, CO 80214 CCN 065209 | 3.7 km | 140 | Aug 19, 2026 | 181 harm1 open | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 065097 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 065097 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Dec 5, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 29, 2025 |
| Dec 5, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 29, 2025 |
| Dec 5, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 29, 2025 |
| Dec 5, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 5, 2025 |
| Dec 5, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 29, 2025 |
| Dec 5, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 29, 2025 |
| Dec 5, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 29, 2025 |
| Dec 5, 2024 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 5, 2025 |
| Dec 5, 2024 | K-0753 | Have restrictions on the use of highly flammable decorations. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 29, 2025 |
| Dec 5, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 29, 2025 |
| Dec 5, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 1, 2025 |
| Dec 5, 2024 | F-0660 | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 1, 2025 | Complaint |
| Dec 5, 2024 | F-0688 | 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 1, 2025 |
| Dec 5, 2024 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | F · Potential harm Widespread | Corrected Jan 1, 2025 |
| Dec 5, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 1, 2025 |
| Mar 19, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 9, 2024 | Complaint |
| Mar 19, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | F · Potential harm Widespread | Corrected Apr 9, 2024 | Complaint |
| Mar 19, 2024 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Apr 9, 2024 | Complaint |
| Jun 29, 2023 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Sep 25, 2023 |
| Jun 29, 2023 | K-0311 | Have an enclosure around a vertical opening shaft. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Sep 25, 2023 |
| Jun 29, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Sep 25, 2023 |
| Jun 29, 2023 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 25, 2023 |
| Jun 29, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 25, 2023 |
| Jun 29, 2023 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0849 | 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. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Jul 24, 2023 |
| Jun 29, 2023 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Jul 24, 2023 |
| Aug 29, 2019 | K-0222 | 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. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Waiver granted Apr 17, 2020 |
| Aug 29, 2019 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 18, 2019 |
| Aug 29, 2019 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 18, 2019 |
| Aug 29, 2019 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 10, 2019 |
| Aug 29, 2019 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 18, 2019 |
| Aug 29, 2019 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 18, 2019 |
| Aug 29, 2019 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 18, 2019 |
| Aug 29, 2019 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Oct 18, 2019 |
| Aug 29, 2019 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 18, 2019 |
| Aug 29, 2019 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 1, 2019 |
| Aug 29, 2019 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 18, 2019 |
| Aug 29, 2019 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 20, 2019 |
| Aug 29, 2019 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 20, 2019 |
| Aug 29, 2019 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 26, 2019 |
| Aug 29, 2019 | F-0849 | 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. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Oct 9, 2019 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.27 (case-mix index 1.24).
| Corporate officer / director |
| CORPORATE DIRECTOR |
| not provided |
| Mar 1, 2023 |
| Soon Burnam | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 19, 2022 |
| David Dunyon | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2023 |
| Chad Keetch | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2011 |
| Ami Sato | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 9, 2024 |
| Ensign Services Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Sep 19, 2022 |
| Garden Investment Co., LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Christopher Horton | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Dontre Mcdonald | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| 82 |
| Nov 7, 2024 |
343 harm |
| — |
| Rock Canyon Respiratory and Rehabilitation Center 2515 Pitman Pl, Pueblo, CO 81004 CCN 065100Abuse icon | 151 | Aug 6, 2026 | 381 IJ3 harm1 open | $67k |
| The Villas at Sunny Acres 2501 E 104th Ave, Thornton, CO 80233 CCN 065108Abuse icon | 160 | Apr 8, 2026 | 394 harm | $20k |
| Medallion Post Acute Rehabilitation 1719 E Bijou St, Colorado Springs, CO 80909 CCN 065113 | 60 | Jun 16, 2026 | 502 IJ3 harm1 open | $87k |
| Holly Heights Care and Rehabilitation 6000 E Iliff Ave, Denver, CO 80222 CCN 065124 | 133 | Jan 21, 2026 | 451 IJ1 harm3 open | $9,249 |
| Hampden Hills Post Acute 14699 E Hampden Ave, Aurora, CO 80014 CCN 065146 | 218 | Jul 9, 2026 | 45 | — |
| Riverbend Health and Rehabilitation Center 821 Duffield Ct, Loveland, CO 80537 CCN 065165Abuse icon | 100 | Apr 30, 2026 | 432 open | — |