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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D18 | E10 | F6 |
| 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 | |
|---|---|---|---|---|---|---|
| Aug 6, 2026 | Health | Health Complaint | 1 | Potential harm | 1 | Open → |
| Dec 11, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 5, 2025 | Fire safety | Fire Safety Standard | 1 | Potential harm | — | Open → |
| Jun 5, 2025 | Health | Health Complaint, Health Standard | 6 | Potential harm | — | Open → |
| Apr 3, 2025 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Jul 12, 2024 | Health | Health Complaint | 7 | Actual harm | — | Open → |
| Mar 21, 2024 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Mar 21, 2024 | Health | Health Complaint, Health Standard | 10 | Potential harm | — | Open → |
| Dec 15, 2022 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Dec 15, 2022 | Health | Health Standard | 5 | Immediate jeopardy | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Apr 3, 2025 | Civil money penalty (fine) | $36,569 | — | 065100|Fine|115940 |
| Jul 12, 2024 | Civil money penalty (fine) | $30,729 | — | 065100|Fine|115880 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D18 | E10 | F6 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 6, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Plan of correction, not yet verified Aug 28, 2026 | Complaint |
| Dec 11, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | · Potential harm |
“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 |
|---|---|---|---|---|---|
| Soon Burnam | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Sep 9, 2024 |
| Mark Gardner | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jun 1, 2023 |
| David Jorgensen | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | May 31, 2023 |
| Vikas Reddy | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 29, 2020 |
| Mark Gardner | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 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 |
|---|---|---|---|---|---|---|
| Atlas Post Acute 2611 Jones Ave, Pueblo, CO 81004 CCN 065232 | 0.3 km | 146 | May 14, 2026 | 503 harm | $54k | |
| Lakeshore Post Acute and Rehabilitation Center 2701 California St, Pueblo, CO 81004 CCN 065229 | 2 km | 106 | Aug 28, 2025 | 70 | — | |
| Life Care Center of Pueblo 2118 Chatalet Ln, Pueblo, CO 81005 CCN 065269 | 2.9 km | 187 | Feb 26, 2026 | 545 harm | $19k | |
| High Plains Post Acute LLC 1209 W Abriendo Ave, Pueblo, CO 81004 CCN 065355 | 3.3 km | 59 | Aug 11, 2025 | 351 IJ5 harm | $58k | |
| Vista Ridge Care and Rehabilitation 855 Hunter Dr, Pueblo, CO 81001 CCN 065121 | 6.5 km | 90 | Dec 4, 2025 | 511 IJ3 harm4 open | $42k | |
| Pueblo Heights Nursing and Rehabilitation 1601 Constitution Rd, Pueblo, CO 81001 CCN 065169 | 7.5 km | 120 | Apr 14, 2026 | 391 IJ | $20k | |
| The Center at Park West LLC 3727 Parker Blvd, Pueblo, CO 81008 CCN 065427 | 8.2 km | 80 | Jun 25, 2026 | 322 harm | — | |
| University Park Care Center 945 Desert Flower Blvd, Pueblo, CO 81001 CCN 065231 | 8.8 km | 180 | Aug 27, 2026 | 462 harm3 open | $23k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 065100 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 065100 | 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
| Corrected Dec 26, 2025 |
| Complaint |
| Jun 5, 2025 | 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 Aug 1, 2025 |
| Jun 5, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 1, 2025 | Complaint |
| Jun 5, 2025 | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 1, 2025 | Complaint |
| Jun 5, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 1, 2025 | Complaint |
| Jun 5, 2025 | 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 Jul 1, 2025 | Complaint |
| Jun 5, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 1, 2025 | Complaint |
| Jun 5, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jul 1, 2025 | Complaint |
| Apr 3, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | G · Actual harm Isolated | Corrected May 2, 2025 | Complaint |
| Jul 12, 2024 | 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 | G · Actual harm Isolated | Corrected Aug 9, 2024 | Complaint |
| Jul 12, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Aug 9, 2024 | Complaint |
| Jul 12, 2024 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 9, 2024 | Complaint |
| Jul 12, 2024 | 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 Aug 9, 2024 | Complaint |
| Jul 12, 2024 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Aug 9, 2024 | Complaint |
| Jul 12, 2024 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Aug 9, 2024 | Complaint |
| Jul 12, 2024 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 9, 2024 | Complaint |
| Mar 21, 2024 | 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 | Corrected Jun 7, 2024 |
| Mar 21, 2024 | K-0331 | Construct fire resistant interior walls. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 24, 2024 |
| Mar 21, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 24, 2024 |
| Mar 21, 2024 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 12, 2024 | Complaint |
| Mar 21, 2024 | F-0622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 12, 2024 |
| Mar 21, 2024 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 12, 2024 | Complaint |
| Dec 15, 2022 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected Jan 14, 2023 |
| Dec 15, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 12, 2023 |
| Dec 15, 2022 | 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 |
| Dec 15, 2022 | 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 Jan 17, 2023 |
| Dec 15, 2022 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 14, 2023 |
| Dec 15, 2022 | 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 | D · Potential harm Isolated | Corrected Jan 14, 2023 |
| Dec 15, 2022 | F-0742 | 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 14, 2023 |
| Dec 15, 2022 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 14, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 2.39 (case-mix index 1.67).
| Operational / managerial control |
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Jan 1, 2015 |
| Barry Port | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2022 |
| Soon Burnam | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 9, 2024 |
| Chad Keetch | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 1, 2022 |
| Ensign Services Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2022 |
| Kettle Creek Health Holdings LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2022 |
| Standard Bearer Healthcare Op LP | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2022 |
| The Ensign Group Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2022 |
| Mark Gardner | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 1, 2023 |
| Vikas Reddy | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 28, 2025 |
| 82 |
| Nov 7, 2024 |
343 harm |
| — |
| Mapleton Post Acute 115 Ingalls St, Lakewood, CO 80226 CCN 065097 | 90 | Jun 17, 2025 | 611 harm | — |
| 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 | — |