Overall Score
CMS Five-Star Quality RatingBelow averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- ColoradoAbove only 14% of peers208 rated homes · average 3.1★
- Denver CountyAbove only 5% of peers22 rated homes · average 3.1★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.7 vs CO avg
- StaffingCan add or remove a star2★−1.1 vs CO avg
- Quality measuresCan add or remove a star5★+0.8 vs CO avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCO avg2.7★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 13% of peersCO avg3.1★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 50% of peersCO avg4.2★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.01hrsAbove only 10% of peersCO avg3.73Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.47hrsAbove only 8% of peersCO avg0.83Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better37%Above 78% of peersCO avg49%RN turnover24%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$66,307Above only 12% of peersCO avg$25,587Fines · denials2 · 1
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles37citations
8inspection dates
3actual harm (G–I)
1immediate jeopardy (J–L)
Dec 4, 2025most recent
Citations by monthAug 2021 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 4, 2025Cycle 1worst D · no actual harm
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsD · isolatedCorrected Dec 10, 2025
Jul 29, 2024Cycle 2worst G · actual harm$53,372, payment denial
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Sep 6, 2024
- F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected Sep 6, 2024
- F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Sep 6, 2024
- F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care PlanningE · patternCorrected Sep 6, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Sep 6, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesF · widespreadCorrected Sep 6, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationD · isolatedCorrected Sep 6, 2024
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationF · widespreadCorrected Sep 6, 2024
- F774Help the resident with transportation to and from laboratory services outside of the facility.AdministrationD · isolatedCorrected Sep 6, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Sep 6, 2024
- F622Not 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 RightsE · patternCorrected Sep 6, 2024
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsD · isolatedCorrected Sep 6, 2024
Mar 7, 2024Cycle 1worst K · immediate jeopardy$12,935
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 30, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 30, 2024
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Mar 30, 2024
- F693Ensure 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 CareD · isolatedCorrected Mar 30, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareK · patternCorrected Mar 15, 2024
- F761Ensure 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 ServiceE · patternCorrected Mar 30, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 30, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Mar 30, 2024
Oct 25, 2023Cycle 3worst D · no actual harm
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Nov 11, 2023
Sep 28, 2023Cycle 3worst E · no actual harm
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Nov 17, 2023
Mar 1, 2023Cycle 3worst E · no actual harm
- F282Provide care by qualified persons according to each resident's written plan of care.Resident Assessment and Care PlanningE · patternCorrected Mar 24, 2023
- F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Resident RightsD · isolatedCorrected Mar 24, 2023
Dec 15, 2022Cycle 2worst E · no actual harm
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Feb 24, 2023
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Feb 24, 2023
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Feb 15, 2023
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsE · patternCorrected Feb 24, 2023
- F656Develop 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 PlanningD · isolatedCorrected Jan 10, 2023
Aug 26, 2021Cycle 3worst G · actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 17, 2021
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Sep 30, 2021
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Sep 30, 2021
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Sep 30, 2021
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareG · isolatedCorrected Sep 30, 2021
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Sep 30, 2021
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 30, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.01hrs
- Registered nursesRN hours only0.47hrs
- Licensed practical nursesLPN hours0.85hrs
- Nurse aidesCNA hours1.69hrs
- Weekend nursingAll staff on Saturdays and Sundays2.84hrs
- Colorado average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better37%Above 78% of peersCO avg 49%
- RN turnoverRegistered nurses only24%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy160 certified beds · ~143 residents a day89%Above 71% of peersCO avg 79%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $66,307In fines
- 2Fines
- 1Payment denial
- $25,587CO avg in fines
Above only 12% of peersFewer fines than 12% of rated homes in Colorado
Actions on record
- Jul 29, 2024Civil money penalty$53,372
- Jul 29, 2024Denial of payment for new admissionsfrom Aug 27, 2024
- Mar 7, 2024Civil money penalty$12,935
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Pacs Group254 facilities in the chain2.9★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Panther Master Tenant, LLC
Indirect owners (5%+)
- Pacs Group, INC.
- Pacs Holdings, LLC
- Providence Group Nh, LLC
- Mark Hancock
- Jason Murray
Corporate officers
- Frederick Apt
- Mark Hancock
- Joshua Jergensen
- John Mitchell
Contracted managers
- Christopher Horton
Managing employees
- Jonathan Ashcroft
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 065241 · 290 S MONACO PKWY, DENVER, CO, 80224.
- Percentiles compare this facility with every rated nursing home in Colorado and Denver County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
