D67

CITY PARK HEALTHCARE AND REHABILITATION CENTER

Grade D 67/100 composite score

For profit - PartnershipAbuse Citation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
5/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

125

Ownership

For profit - Partnership

Total Fines

None

Last Survey

N/A

1667 SAINT PAUL ST, DENVER, CO 80206
3033992040

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.52h
LPN
0.55h
CNA
1.94h
Total
3.00h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

ENDURA HEALTHCARE LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Feb 2024

100%

THE ENSIGN GROUP INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2024

100%

ONSHIFT INC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Aug 2024

ROCKY MOUNTAIN RESPIRATORY RESOURCE

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Aug 2024

GAHM, GREGORY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Aug 2024

WONDMAGEGN, FASIL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Aug 2024

JORGENSEN, DAVID

IndividualCORPORATE DIRECTORSince Feb 2024

BURNAM, SOON

IndividualCORPORATE OFFICERSince Feb 2024

GRAHAM, JOSEPH

IndividualCORPORATE OFFICERSince Feb 2024

KEETCH, CHAD

IndividualCORPORATE OFFICERSince Mar 2011

SATO, AMI

IndividualCORPORATE OFFICERSince Sep 2024

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (55)

October 30, 2025Health1 deficiency1 severe
0600GActual harm, Isolated

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

Corrected Nov 24, 2025
March 18, 2024Health1 deficiency
0600DMinimal harm, Isolated

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

Corrected Apr 12, 2024
January 11, 2024Health3 deficiencies
0585EMinimal harm, Pattern

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Feb 23, 2024
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Feb 23, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Feb 23, 2024
October 12, 2023Health17 deficiencies
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Nov 11, 2023
0584DMinimal harm, Isolated

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

Corrected Nov 11, 2023
0600DMinimal harm, Isolated

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

Corrected Nov 15, 2023
0604DMinimal harm, Isolated

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 15, 2023
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 11, 2023
0646EMinimal harm, Pattern

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 11, 2023
0676DMinimal harm, Isolated

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

Corrected Nov 11, 2023
0678DMinimal harm, Isolated

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies

Corrected Nov 11, 2023
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Nov 11, 2023
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Nov 11, 2023
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Dec 21, 2023
0742DMinimal harm, Isolated

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

Corrected Nov 11, 2023
0744DMinimal harm, Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Corrected Nov 11, 2023
0761EMinimal harm, Pattern

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

Corrected Nov 29, 2023
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Nov 11, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 11, 2023
0602EMinimal harm, Pattern

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 11, 2023
June 1, 2023Health1 deficiency
0582FMinimal harm, Widespread

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Corrected Jul 1, 2023
July 14, 2022Health10 deficiencies
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Aug 12, 2022
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 12, 2022
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 12, 2022
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 12, 2022
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 18, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Aug 12, 2022
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Aug 12, 2022
0806DMinimal harm, Isolated

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

Corrected Aug 12, 2022
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Aug 12, 2022
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 12, 2022
April 15, 2021Health22 deficiencies1 severe
0610EMinimal harm, Pattern

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 14, 2021
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected May 14, 2021
0570FMinimal harm, Widespread

Assure the security of all personal funds of residents deposited with the facility.

Resident Rights Deficiencies

Corrected May 14, 2021
0600EMinimal harm, Pattern

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

Corrected May 14, 2021
0636EMinimal harm, Pattern

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Corrected May 14, 2021
0676DMinimal harm, Isolated

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

Corrected May 14, 2021
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected May 14, 2021
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected May 14, 2021
0685DMinimal harm, Isolated

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Corrected May 14, 2021
0688DMinimal harm, Isolated

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

Corrected May 14, 2021
0689KImmediate jeopardy, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 14, 2021
0690EMinimal harm, Pattern

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

Corrected May 14, 2021
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected May 14, 2021
0744DMinimal harm, Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Corrected May 14, 2021
0758EMinimal harm, Pattern

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected May 14, 2021
0761EMinimal harm, Pattern

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

Corrected May 14, 2021
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected May 14, 2021
0810FMinimal harm, Widespread

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Nutrition and Dietary Deficiencies

Corrected May 14, 2021
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected May 14, 2021
0838FMinimal harm, Widespread

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

Corrected May 14, 2021
0865FMinimal harm, Widespread

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies

Corrected May 14, 2021
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 30, 2021

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Frequently Asked Questions

What is the CareGrader rating for CITY PARK HEALTHCARE AND REHABILITATION CENTER?

CITY PARK HEALTHCARE AND REHABILITATION CENTER in DENVER, Colorado has a CareGrader grade of D (Below Average), with a composite score of 66.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for CITY PARK HEALTHCARE AND REHABILITATION CENTER?

CITY PARK HEALTHCARE AND REHABILITATION CENTER has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does CITY PARK HEALTHCARE AND REHABILITATION CENTER have?

CITY PARK HEALTHCARE AND REHABILITATION CENTER has 55 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

How many beds does CITY PARK HEALTHCARE AND REHABILITATION CENTER have?

CITY PARK HEALTHCARE AND REHABILITATION CENTER has 125 certified beds with approximately 117 current residents (94% occupancy). The facility is located at 1667 SAINT PAUL ST, DENVER, Colorado 80206. It is a for profit - partnership facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.