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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D17 | E8 | F18 |
| 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 | |
|---|---|---|---|---|---|---|
| Apr 30, 2026 | Fire safety | Fire Safety Standard | 6 | Potential harm | 1 | Open → |
| Apr 30, 2026 | Health | Health Standard | 7 | Potential harm | — | Open → |
| Jun 27, 2024 | Fire safety | Fire Safety Standard | 15 | Potential harm | — | Open → |
| Jun 27, 2024 | Health | Health Standard | 3 | Potential harm | — | Open → |
| Feb 9, 2023 | Fire safety | Fire Safety Standard | 4 | Potential harm | 1 | Open → |
| Feb 9, 2023 | Health | Health Standard | 8 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D17 | E8 | F18 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Apr 30, 2026 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 30, 2026 | |
| Apr 30, 2026 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 30, 2026 | |
| Apr 30, 2026 | K-0353 |
“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 |
|---|---|---|---|---|---|
| Jameel Chohan | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Sep 1, 2024 |
| Courtney Deckman | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Sep 1, 2024 |
| Courtney Deckman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2024 |
| David Jorgensen | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | May 24, 2024 |
| Soon Burnam | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | May 24, 2024 |
| Joseph Graham | Individual | Corporate officer / director |
| 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 |
|---|---|---|---|---|---|---|
| North Shore Health & Rehab Facility 1365 W 29th St, Loveland, CO 80538 CCN 065129 | 2.5 km | 134 | Jul 9, 2026 | 491 harm4 open | — | |
| The Green House Homes at Mirasol 490 Mirasol Dr, Loveland, CO 80537 CCN 065412 | 2.9 km | 90 | Mar 12, 2025 | 30 | $7,544 | |
| Good Samaritan - Loveland Village 2101 S Garfield Ave, Loveland, CO 80537 CCN 065139Abuse icon | 3.4 km | 104 | Apr 2, 2026 | 271 IJ4 harm | $46k | |
| Berthoud Care and Rehabilitation 855 Franklin Ave, Berthoud, CO 80513 CCN 065265 | 10.1 km | 76 | Jun 2, 2026 | 354 open | — | |
| Good Samaritan Society -- Fort Collins Village 508 W Trilby Rd, Fort Collins, CO 80525 CCN 065227 | 10.5 km | 64 | Dec 4, 2025 | 22 | — | |
| Lemay Avenue Health and Rehab LLC 4824 S Lemay Ave, Fort Collins, CO 80525 CCN 065142 | 13.6 km | 130 | Jun 1, 2026 | 191 harm | $55k | |
| Columbine Commons Health and Rehab LLC 1475 Main St, Windsor, CO 80550 CCN 065410 | 16.2 km | 60 | Apr 17, 2025 | 331 open | — | |
| Centre Avenue Health and Rehab LLC 815 Centre Ave, Fort Collins, CO 80526 CCN 065377 | 17.3 km | 90 | May 21, 2026 | 202 harm1 open | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 065165 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 065165 | 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
| Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety |
| E · Potential harm Pattern |
| Corrected May 29, 2026 |
| Apr 30, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 15, 2026 |
| Apr 30, 2026 | 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 | Plan of correction, not yet verified |
| Apr 30, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 18, 2026 |
| Apr 30, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 22, 2026 |
| Apr 30, 2026 | F-0568 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 22, 2026 |
| Apr 30, 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 | Corrected May 22, 2026 |
| Apr 30, 2026 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Past non-compliance Apr 22, 2026 |
| Apr 30, 2026 | 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 May 22, 2026 |
| Apr 30, 2026 | 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 | D · Potential harm Isolated | Corrected May 22, 2026 |
| Apr 30, 2026 | 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 | F · Potential harm Widespread | Corrected May 22, 2026 |
| Jun 27, 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 | F · Potential harm Widespread | Corrected Aug 27, 2024 |
| Jun 27, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 5, 2024 |
| Jun 27, 2024 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 14, 2024 |
| Jun 27, 2024 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Waiver granted Apr 30, 2025 |
| Jun 27, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 27, 2024 |
| Jun 27, 2024 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 14, 2024 |
| Jun 27, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 14, 2024 |
| Jun 27, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 27, 2024 |
| Jun 27, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 21, 2024 |
| Jun 27, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 27, 2024 |
| Jun 27, 2024 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 27, 2024 |
| Jun 27, 2024 | K-0907 | Ensure medical gas and vacuum systems have documented maintenance programs. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 27, 2024 |
| Jun 27, 2024 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 27, 2024 |
| Jun 27, 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 | F · Potential harm Widespread | Corrected Aug 27, 2024 |
| Jun 27, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 27, 2024 |
| Jun 27, 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 Jul 22, 2024 |
| Jun 27, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 22, 2024 |
| Jun 27, 2024 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jul 22, 2024 |
| Feb 9, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 20, 2023 |
| Feb 9, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Feb 9, 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 | Plan of correction, not yet verified Mar 16, 2023 |
| Feb 9, 2023 | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 20, 2023 |
| Feb 9, 2023 | 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 Mar 11, 2023 |
| Feb 9, 2023 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 15, 2023 |
| Feb 9, 2023 | 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 Mar 11, 2023 |
| Feb 9, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 11, 2023 |
| Feb 9, 2023 | F-0790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 11, 2023 |
| Feb 9, 2023 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 11, 2023 |
| Feb 9, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 11, 2023 |
| Feb 9, 2023 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 11, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.14 (case-mix index 1.38).
| CORPORATE OFFICER |
| not provided |
| May 24, 2024 |
| David Jorgensen | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | May 24, 2024 |
| Ami Sato | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 9, 2024 |
| Jameel Chohan | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 1, 2024 |
| Courtney Deckman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 6, 2025 |
| 82 |
| Nov 7, 2024 |
343 harm |
| — |
| Mapleton Post Acute 115 Ingalls St, Lakewood, CO 80226 CCN 065097 | 90 | Jun 17, 2025 | 611 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 | — |