SFF Candidate

Overview

Address
3185 W ARKANSAS AVE, DENVER, CO 80219
Phone
3039221169
Certified beds
85
Avg daily residents
68 (80% of beds filled)
Ownership
For-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1990-04-01
Setting
Urban
2 /5
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
2/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
4/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
5/5
Quality Measures breakdown
Long-Stay Quality Measures 5/5
Short-Stay Quality Measures Data not available.

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
3.44 3.38 3.93 ≥ 3.48 Below floor
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
0.61 0.59 0.70 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
0.65 0.75 0.74
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
2.18 2.04 2.49
Licensed (RN + LPN)
Combined licensed nurse coverage.
1.26
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
0.08

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
2.85
hrs / resident / day
RN (weekend)
0.46
hrs / resident / day
Total nurse (adjusted, weekend)
3.26
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
36.2%
annual
RN turnover
54.5%
annual
Administrators departed
1
last 12 months

Resident acuity

Nursing Case-Mix Index
1.20
higher acuity than avg
Case-Mix Index Ratio
0.87
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-04-25 21 21 2 191 1 191
Cycle 2/3 (prior) 2023-09-28 22 5 18 271 1 271
Total weighted health score
211.0
lower is better

Deficiencies (50)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

1 A/B/C No actual harm — minor
43 D/E/F Actual harm — potential for minor
4 G/H/I Actual harm
2 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0567 Honor the resident's right to manage his or her financial affairs. E 2025-04-25 2025-05-09
0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. C 2025-04-25 2025-05-01
0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. D 2025-04-25 2025-05-15
0659 Provide care by qualified persons according to each resident's written plan of care. D 2025-04-25 2025-05-15
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2025-04-25 2025-05-16
0679 Provide activities to meet all resident's needs. D 2025-04-25 2025-05-15
0685 Assist a resident in gaining access to vision and hearing services. D 2025-04-25 2025-05-15
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2025-04-25 2025-04-30
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2025-04-25 2025-05-15
0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. D 2025-04-25 2025-05-15
0699 Provide care or services that was trauma informed and/or culturally competent. D 2025-04-25 2025-05-15
0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. E 2025-04-25 2025-05-15
0791 Provide or obtain dental services for each resident. D 2025-04-25 2025-05-15
0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. E 2025-04-25 2025-05-01
0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. E 2025-04-25 2025-05-15
0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. F 2025-04-25 2025-05-12
0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F 2025-04-25 2025-05-15
0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. D 2025-04-25 2025-05-15
0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. D 2025-04-25 2025-05-15
0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. D 2025-04-25 2025-05-01
0626 Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. D 2025-04-25 2025-05-15
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. E 2024-03-07 2024-04-30
0565 Honor the resident's right to organize and participate in resident/family groups in the facility. E 2024-03-07 2024-04-30
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. D 2024-03-07 2024-04-30
0585 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. D 2024-03-07 2024-04-30
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. G 2024-03-07 2024-04-30
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2024-03-07 2024-04-30
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. E 2024-03-07 2024-04-30
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. G 2024-03-07 2024-04-30
0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. D 2024-03-07 2024-04-30
0692 Provide enough food/fluids to maintain a resident's health. G 2024-03-07 2024-04-05
0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. E 2024-03-07 2024-04-30
0760 Ensure that residents are free from significant medication errors. J 2024-03-07 2024-04-30
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. D 2024-03-07 2024-04-30
0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. E 2024-03-07 2024-04-30
0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. D 2024-03-07 2024-04-30
0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F 2024-03-07 2024-04-05
0880 Provide and implement an infection prevention and control program. D 2024-03-07 2024-04-30
0552 Ensure that residents are fully informed and understand their health status, care and treatments. E 2023-09-28 2023-10-21
0760 Ensure that residents are free from significant medication errors. G 2023-09-28 2023-10-21
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. E 2023-09-28 2023-10-21
0880 Provide and implement an infection prevention and control program. E 2023-09-28 2023-10-21
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. E 2023-09-28 2023-10-21
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. E 2020-02-27 2020-04-10
0679 Provide activities to meet all resident's needs. D 2020-02-27 2020-03-18
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2020-02-27 2020-03-27
0692 Provide enough food/fluids to maintain a resident's health. D 2020-02-27 2020-03-27
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2020-02-27 2020-03-27
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F 2020-02-27 2020-04-11
0880 Provide and implement an infection prevention and control program. E 2020-02-27 2020-04-02

Penalties (5)

Fines issued
3
last 3 years
Total fines
$65,470
Payment denials
2
Date Type Fine amount
2023-09-28 Fine $12,334
2025-04-25 Fine $23,959
2024-03-07 Fine $29,177
2025-04-25 Payment Denial
2024-03-07 Payment Denial

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 1.0% Medicaid 64.9% Other 34.1%

Operating performance

Operating Margin
-6.0%
Total Margin
-6.0%
Occupancy Rate
90.7%

Revenue & costs

Net Patient Revenue
$7.6M
Total Costs
$416K
Net Income
-$455K

Balance sheet

Total Assets
$1.5M
Total Liabilities
$1.9M
Fund Balance
-$455K
Current Ratio
0.64

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: PACS GROUP

Chain ID
690
Facilities in chain
264
Legal business name
NORTH STAR HEALTHCARE LLC
Chain-average star ratings (for peer context)
Overall
2.9
Health
2.6
Staffing
2.4
QM
4.2

Owner / manager organizations (4)

Organization Role Association
CENTENNIAL MASTER TENANT, LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 10/11/2022
PACS GROUP, INC. 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 06/30/2023
PACS HOLDINGS, LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 06/30/2023
PROVIDENCE GROUP NH, LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 06/30/2023

Owner / manager individuals (8)

Name Role Association
HANCOCK, MARK 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 04/15/2024
MURRAY, JASON 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 04/15/2024
APT, FREDERICK CORPORATE OFFICER since 10/11/2022
HANCOCK, MARK CORPORATE OFFICER since 10/11/2022
JERGENSEN, JOSHUA CORPORATE OFFICER since 01/01/2024
MITCHELL, JOHN CORPORATE OFFICER since 10/11/2022
HORTON, CHRISTOPHER CONTRACTED MANAGING EMPLOYEE since 04/20/2023
CONNOR, ANGELA W-2 MANAGING EMPLOYEE since 02/12/2024

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Special focus status
SFF Candidate
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 112 rows
Source Metric Value Raw key
Cost Report Current Ratio 0.64 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 64.9% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 1.0% metrics.medicare_day_share
Cost Report Net Income ($) $-454,888 metrics.net_income
Cost Report Net Patient Revenue ($) $7,610,152 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 90.7% metrics.occupancy_rate
Cost Report Operating Margin (%) -6.0% metrics.operating_margin
Cost Report Total Assets ($) $1,464,898 metrics.total_assets
Cost Report Total Costs ($) $416,050 metrics.total_costs
Cost Report Total Fund Balances ($) $-454,888 metrics.fund_balance
Cost Report Total Liabilities ($) $1,919,786 metrics.total_liabilities
Cost Report Total Margin (%) -6.0% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.74274 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 2.49130 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.69968 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.93373 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.26177 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 68.0 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.74915 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.03602 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.59049 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.37566 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 2.97529 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.6 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.9 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.2 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.4 Chain Average Staffing Rating
Provider Information Chain ID 690 Chain ID
Provider Information Chain Name PACS GROUP Chain Name
Provider Information City/Town DENVER City/Town
Provider Information CMS Certification Number (CCN) 065274 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Denver County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1990-04-01 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote Health Inspection Rating Footnote
Provider Information Latitude 39.6913 Latitude
Provider Information Legal Business Name NORTH STAR HEALTHCARE LLC Legal Business Name
Provider Information Location 3185 W ARKANSAS AVE,DENVER,CO,80219 Location
Provider Information Long-Stay QM Rating 5 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote Long-Stay QM Rating Footnote
Provider Information Longitude -105.03 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 1 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 85 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 264 Number of Facilities in Chain
Provider Information Number of Fines 3 Number of Fines
Provider Information Number of Payment Denials 2 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.19584 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.86803 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 2 Overall Rating
Provider Information Overall Rating Footnote Overall Rating Footnote
Provider Information Ownership Type For profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 3185 W ARKANSAS AVE Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name WESTWOOD POST ACUTE Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 150 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 5 QM Rating
Provider Information QM Rating Footnote QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 191 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 2 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 21 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-04-25 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 191 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 21 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 5 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-09-28 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 271 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 18 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 271 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 22 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.45749 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 54.5 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.26113 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.64939 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.17818 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.08317 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.61174 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.43931 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote 2 Short-Stay QM Rating Footnote
Provider Information Special Focus Status SFF Candidate Special Focus Status
Provider Information Staffing Rating 4 Staffing Rating
Provider Information Staffing Rating Footnote Staffing Rating Footnote
Provider Information State CO State
Provider Information Telephone Number 3039221169 Telephone Number
Provider Information Total Amount of Fines in Dollars 65470.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 2.85181 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 5 Total Number of Penalties
Provider Information Total nursing staff turnover 36.2 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 211.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 80219 ZIP Code