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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L· |
| Actual harm | G9 | H· | I· |
| Potential harm | D39 | E30 | F38 |
| Minimal | A· | B· | C1 |
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 | |
|---|---|---|---|---|---|---|
| Feb 26, 2026 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Dec 18, 2025 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Sep 11, 2025 | Fire safety | Fire Safety Standard | 14 | Potential harm | 2 | Open → |
| Sep 11, 2025 | Health | Health Complaint, Health Standard | 6 | Potential harm | — | Open → |
| Jun 12, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jan 29, 2025 | Health | Health Complaint | 6 | Actual harm | — | Open → |
| Apr 10, 2024 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Apr 10, 2024 | Health | Health Complaint, Health Standard | 16 | Actual harm | — | Open → |
| Oct 9, 2023 | Health | Health Complaint | 13 | Immediate jeopardy | — | Open → |
| Nov 17, 2022 | Fire safety | Fire Safety Standard | 20 | Potential harm | — | Open → |
| Nov 17, 2022 | Health | Health Standard | 18 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jan 29, 2025 | Denial of payment for new admissions | — | Feb 27, 2025 · 8 days | 065248|Payment Denial|2025-02-27 |
| Jan 29, 2025 | Civil money penalty (fine) | $53,151 | — | 065248|Fine|115925 |
| Apr 10, 2024 | Civil money penalty (fine) | $52,416 | — | 065248|Fine|115852 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L· |
| Actual harm | G9 | H· | I· |
| Potential harm | D39 | E30 | F38 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Feb 26, 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 | E · Potential harm Pattern | Corrected Mar 23, 2026 | Complaint |
| Feb 26, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 23, 2026 | 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 | Jul 15, 2025 |
| Eddy Boyles | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Dec 18, 2023 |
| Gregory Gahm | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jun 26, 2024 |
| Kare Technologies LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2024 |
| Onshift Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2024 |
| Sos Nursing Services, Inc |
| 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 |
|---|---|---|---|---|---|---|
| Mapleton Post Acute 115 Ingalls St, Lakewood, CO 80226 CCN 065097 | 0.9 km | 90 | Jun 17, 2025 | 611 harm | — | |
| Sierra Post Acute 1432 Depew St, Lakewood, CO 80214 CCN 065272Abuse icon | 2.4 km | 102 | Jul 13, 2026 | 411 IJ5 harm | $55k | |
| Cedars Healthcare Center 1599 Ingalls St, Lakewood, CO 80214 CCN 065202 | 2.8 km | 130 | Jun 11, 2026 | 582 IJ2 open | $16k | |
| Edgewater Health and Rehabilitation 1655 Eaton St, Lakewood, CO 80214 CCN 065171 | 2.9 km | 67 | Aug 27, 2025 | 291 harm | — | |
| Cambridge Care Center 1685 Eaton St, Lakewood, CO 80214 CCN 065296Abuse icon | 2.9 km | 110 | Jun 11, 2026 | 391 harm | $8,151 | |
| Sloan's Lake Rehabilitation Center 1601 Lowell Blvd, Denver, CO 80204 CCN 065404 | 3.2 km | 42 | Mar 5, 2026 | 18 | — | |
| Westwood Post Acute 3185 W Arkansas Ave, Denver, CO 80219 CCN 065274SFF Candidate | 3.5 km | 85 | Apr 25, 2025 | 772 IJ4 harm | $53k | |
| Parkview Care Center 3105 W Arkansas Ave, Denver, CO 80219 CCN 065299 | 3.5 km | 73 | May 21, 2026 | 26 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 065248 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 065248 | 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
| Feb 26, 2026 | 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 Mar 23, 2026 | Complaint |
| Feb 26, 2026 | 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 Mar 23, 2026 | Complaint |
| Feb 26, 2026 | 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 Mar 23, 2026 | Complaint |
| Feb 26, 2026 | F-0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 23, 2026 | Complaint |
| Dec 18, 2025 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 31, 2025 | Complaint |
| Dec 18, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 15, 2026 | Complaint |
| Dec 18, 2025 | 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 Dec 23, 2025 | Complaint |
| Dec 18, 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 Jan 15, 2026 | Complaint |
| Sep 11, 2025 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Plan of correction, not yet verified |
| Sep 11, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 31, 2026 |
| Sep 11, 2025 | 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 Jan 31, 2026 |
| Sep 11, 2025 | K-0252 | Provide at least two remote exits on each floor or fire section of the building. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Plan of correction, not yet verified |
| Sep 11, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 31, 2026 |
| Sep 11, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 31, 2026 |
| Sep 11, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 31, 2026 |
| Sep 11, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 31, 2026 |
| Sep 11, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 31, 2026 |
| Sep 11, 2025 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 31, 2026 |
| Sep 11, 2025 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 31, 2026 |
| Sep 11, 2025 | 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 | F · Potential harm Widespread | Corrected Jan 31, 2026 |
| Sep 11, 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 Jan 31, 2026 |
| Sep 11, 2025 | K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 31, 2026 |
| Sep 11, 2025 | 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 Oct 10, 2025 |
| Sep 11, 2025 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 10, 2025 |
| Sep 11, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Oct 10, 2025 |
| Sep 11, 2025 | 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 Oct 10, 2025 | Complaint |
| Sep 11, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Oct 10, 2025 | Complaint |
| Sep 11, 2025 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Oct 10, 2025 |
| Jun 12, 2025 | 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 | E · Potential harm Pattern | Corrected Jul 4, 2025 | Complaint |
| Jun 12, 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 4, 2025 | Complaint |
| Jun 12, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 4, 2025 | Complaint |
| Jan 29, 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 Mar 7, 2025 | Complaint |
| Jan 29, 2025 | 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 Mar 7, 2025 | Complaint |
| Jan 29, 2025 | 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 Mar 7, 2025 | Complaint |
| Jan 29, 2025 | 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 Mar 7, 2025 | Complaint |
| Jan 29, 2025 | 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 Mar 7, 2025 | Complaint |
| Jan 29, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 7, 2025 | Complaint |
| Apr 10, 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 | G · Actual harm Isolated | Corrected May 5, 2024 | Complaint |
| Apr 10, 2024 | K-0231 | Provide large enough exits. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 1, 2024 |
| Apr 10, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2024 |
| Apr 10, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Waiver granted Jul 28, 2024 |
| Apr 10, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Jul 28, 2024 |
| Apr 10, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2024 |
| Apr 10, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2024 |
| Apr 10, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Jun 28, 2024 |
| Apr 10, 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 | Waiver granted Jun 28, 2024 |
| Apr 10, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2024 |
| Apr 10, 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 Jul 1, 2024 |
| Apr 10, 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 | Waiver granted Jul 28, 2024 |
| Apr 10, 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 Jul 1, 2024 |
| Apr 10, 2024 | 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 May 2, 2024 | Complaint |
| Apr 10, 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 | D · Potential harm Isolated | Corrected May 5, 2024 | Complaint |
| Apr 10, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 5, 2024 | Complaint |
| Apr 10, 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 | D · Potential harm Isolated | Corrected May 5, 2024 | Complaint |
| Apr 10, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 5, 2024 |
| Apr 10, 2024 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 5, 2024 |
| Apr 10, 2024 | 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 May 2, 2024 |
| Apr 10, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 5, 2024 | Complaint |
| Apr 10, 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 | E · Potential harm Pattern | Corrected May 5, 2024 | Complaint |
| Apr 10, 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 | D · Potential harm Isolated | Corrected May 2, 2024 |
| Apr 10, 2024 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 5, 2024 | Complaint |
| Apr 10, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 2, 2024 | Complaint |
| Apr 10, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 2, 2024 | Complaint |
| Apr 10, 2024 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 5, 2024 |
| Oct 9, 2023 | 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 | K · Immediate jeopardy Pattern | Corrected Nov 24, 2023 | Complaint |
| Oct 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 | G · Actual harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 9, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 9, 2023 | 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 Nov 9, 2023 | Complaint |
| Oct 9, 2023 | 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 | G · Actual harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 9, 2023 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 9, 2023 | 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 Nov 28, 2023 | Complaint |
| Oct 9, 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 Nov 9, 2023 | Complaint |
| Oct 9, 2023 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Nov 9, 2023 | Complaint |
| Oct 9, 2023 | F-0838 | 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. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 9, 2023 | Complaint |
| Oct 9, 2023 | 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 | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 9, 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 Nov 9, 2023 | Complaint |
| Oct 9, 2023 | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Nov 9, 2023 | Complaint |
| Nov 17, 2022 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Dec 23, 2022 |
| Nov 17, 2022 | 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 Dec 22, 2022 |
| Nov 17, 2022 | E-0001 | Establish an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 17, 2022 |
| Nov 17, 2022 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 17, 2022 |
| Nov 17, 2022 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 17, 2022 |
| Nov 17, 2022 | E-0029 | Develop a communication plan. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 17, 2022 |
| Nov 17, 2022 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 17, 2022 |
| Nov 17, 2022 | 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 | Waiver granted Mar 31, 2023 |
| Nov 17, 2022 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 30, 2022 |
| Nov 17, 2022 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 30, 2022 |
| Nov 17, 2022 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 30, 2022 |
| Nov 17, 2022 | 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 Dec 30, 2022 |
| Nov 17, 2022 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 30, 2022 |
| Nov 17, 2022 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Mar 31, 2023 |
| Nov 17, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Mar 31, 2023 |
| Nov 17, 2022 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Mar 31, 2023 |
| Nov 17, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted Mar 31, 2023 |
| Nov 17, 2022 | K-0364 | Install properly constructed windows in hallway walls or doors. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 30, 2022 |
| Nov 17, 2022 | K-0371 | Have properly sized and located compartments to protect residents from smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Mar 31, 2023 |
| Nov 17, 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 Mar 31, 2023 |
| Nov 17, 2022 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 30, 2022 |
| Nov 17, 2022 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 30, 2022 |
| Nov 17, 2022 | F-0567 | Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 17, 2022 |
| Nov 17, 2022 | 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 Dec 17, 2022 |
| Nov 17, 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 Dec 17, 2022 |
| Nov 17, 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 | E · Potential harm Pattern | Corrected Dec 17, 2022 |
| Nov 17, 2022 | 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 Dec 17, 2022 |
| Nov 17, 2022 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 17, 2022 |
| Nov 17, 2022 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 17, 2022 |
| Nov 17, 2022 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 17, 2022 |
| Nov 17, 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 | E · Potential harm Pattern | Corrected Dec 17, 2022 |
| Nov 17, 2022 | 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 Dec 17, 2022 |
| Nov 17, 2022 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 17, 2022 |
| Nov 17, 2022 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 17, 2022 |
| Nov 17, 2022 | 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 Dec 17, 2022 |
| Nov 17, 2022 | 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 | D · Potential harm Isolated | Corrected Dec 17, 2022 |
| Nov 17, 2022 | 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 Dec 17, 2022 |
| Nov 17, 2022 | 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 Dec 17, 2022 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.14 (case-mix index 1.24).
| Organization |
| Operational / managerial control |
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Mar 1, 2024 |
| Eddy Boyles | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 18, 2023 |
| Gregory Gahm | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 26, 2024 |
| David Jorgensen | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Sep 9, 2024 |
| Soon Burnam | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Dec 18, 2023 |
| David Dunyon | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2024 |
| 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 |
| Caretrust Gp LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2024 |
| Caretrust Reit Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2024 |
| Ctr Partnership LP | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2024 |
| Ensign Services Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 18, 2023 |
| Eddy Boyles | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 15, 2025 |
| Soon Burnam | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 15, 2025 |
| Gregory Gahm | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 15, 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 | — |