Your report for Village Care and Rehabilitation Center, the
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- ColoradoAbove only 41% of peers208 rated homes · average 3.1★
- Jefferson CountyAbove only 41% of peers23 rated homes · average 3.0★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point3★+0.3 vs CO avg
- StaffingCan add or remove a star4★+0.9 vs CO avg
- Quality measuresCan add or remove a star3★−1.2 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 cycles3★Above only 49% of peersCO avg2.7★U.S. avg2.8★
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.
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 turnover4★Above 57% of peersCO avg3.1★U.S. avg2.9★
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.
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 assessments3★Above only 7% of peersCO avg4.2★U.S. avg3.6★
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.
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 staff4.17hrsAbove 78% of peersCO avg3.73Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
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 only0.83hrsAbove 61% of peersCO avg0.83Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
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 better57%Above only 30% of peersCO avg49%RN turnover62%
The share of nursing staff who left within the past year, from the same payroll data.
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$23,480Above only 34% of peersCO avg$25,587Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthAug 2019 – Dec 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 19, 2024Cycle 1worst E · no actual harm
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Jan 7, 2025
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jan 8, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jan 6, 2025
Oct 8, 2024Cycle 2worst G · actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 5, 2024
Jun 21, 2023Cycle 2worst E · no actual harm
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jul 7, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jul 24, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 27, 2023
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jul 14, 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 PlanningE · patternCorrected Jul 21, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
Feb 28, 2023Cycle 3worst J · immediate jeopardy$23,480
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareJ · isolatedCorrected Mar 7, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Mar 16, 2023
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 22, 2023
- F843Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.AdministrationF · widespreadCorrected Mar 20, 2023
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Mar 13, 2023
- F947Ensure 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 ServicesF · widespreadCorrected Mar 16, 2023
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Mar 16, 2023
- F688Provide 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 CareD · isolatedCorrected Mar 22, 2023
Aug 29, 2019Cycle 3worst E · no actual harm
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningD · isolatedCorrected Oct 11, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 11, 2019
- F920Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.EnvironmentalE · patternCorrected Oct 11, 2019
- F947Ensure 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 ServicesE · patternCorrected Oct 11, 2019
- 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 Oct 11, 2019
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.17hrs
- Registered nursesRN hours only0.83hrs
- Licensed practical nursesLPN hours0.73hrs
- Nurse aidesCNA hours2.61hrs
- Weekend nursingAll staff on Saturdays and Sundays3.65hrs
- Colorado average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better57%Above only 30% of peersCO avg 49%
- RN turnoverRegistered nurses only62%Not ranked by CMS
- Administrators who leftIn the past year3Leadership changed
- Occupancy60 certified beds · ~55 residents a day92%Above 80% of peersCO avg 79%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $23,480In fines
- 1Fine
- 0Payment denials
- $25,587CO avg in fines
Actions on record
- Feb 28, 2023Civil money penalty$23,480
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Church related
- Chain
- Covenant Living15 facilities in the chain4.3★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Covenant Living Communities & Services
- Jody Holt
- Sarah Bentley
- Pamela Christensen
- Kara Davis
- Mark Eastburg
- Kurt Kincannon
- Matt Manlove
- Robert Martin
- Richard Nelson
- +4 more
- Terri Cunliffe
- David Erickson
- Rebekah Erickson
- Jody Holt
- Terri Cunliffe
- Jody Holt
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 065367 · 9221 WADSWORTH PKWY, WESTMINSTER, CO, 80021.
- Percentiles compare this facility with every rated nursing home in Colorado and Jefferson 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.
