SNF
VILLAGE CARE AND REHABILITATION CENTER, THE
CCN: 065367 · WESTMINSTER, CO 80021 · Jefferson County
CCRC
Overview
- Address
- 9221 WADSWORTH PKWY, WESTMINSTER, CO 80021
- Phone
- 3034032900
- Certified beds
- 60
- Avg daily residents
- 55 (92% of beds filled)
- Ownership
- Non-profit (church-affiliated)
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1998-03-25
- Setting
- Urban
4 /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.
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 | 4.17 | 3.50 | 4.59 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.83 | 0.61 | 0.91 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.73 | 0.78 | 0.81 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.61 | 2.11 | 2.87 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.56 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.06 | — | — | — |
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)
3.65
hrs / resident / day
RN (weekend)
0.67
hrs / resident / day
Total nurse (adjusted, weekend)
4.02
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
56.9%
annual
RN turnover
61.5%
annual
Administrators departed
3
last 12 months
Resident acuity
Nursing Case-Mix Index
1.24
higher acuity than avg
Case-Mix Index Ratio
0.90
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) | 2024-12-19 | 3 | 3 | 0 | 16 | 1 | 16 |
| Cycle 2/3 (prior) | 2023-06-21 | 7 | 6 | 3 | 52 | 1 | 52 |
Total weighted health score
25.0
lower is better
Deficiencies (15)
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).
14 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0679 | Provide activities to meet all resident's needs. | D | 2024-12-19 | 2025-01-07 |
| 0760 | Ensure that residents are free from significant medication errors. | D | 2024-12-19 | 2025-01-08 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2024-12-19 | 2025-01-06 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | 2024-10-08 | 2024-11-05 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | 2023-06-21 | 2023-07-21 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2023-06-21 | 2023-07-28 |
| 0697 | Provide safe, appropriate pain management for a resident who requires such services. | D | 2023-06-21 | 2023-07-07 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2023-06-21 | 2023-07-27 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2023-06-21 | 2023-07-24 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2023-06-21 | 2023-07-14 |
| 0638 | Assure that each resident’s assessment is updated at least once every 3 months. | D | 2019-08-29 | 2019-10-11 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2019-08-29 | 2019-10-11 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2019-08-29 | 2019-10-11 |
| 0920 | Provide 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. | E | 2019-08-29 | 2019-10-11 |
| 0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E | 2019-08-29 | 2019-10-11 |
Financial Health (FY 2023)
Payer mix (share of resident days)
Medicare 6.2% Medicaid 30.9% Other 62.9%
Operating performance
Operating Margin
-6.5%
Total Margin
-4.8%
Occupancy Rate
88.2%
Cost per Resident Day
$36
Revenue & costs
Net Patient Revenue
$8.3M
Total Costs
$690K
Net Income
-$402K
Balance sheet
Total Assets
$5.0M
Total Liabilities
$8.7M
Fund Balance
-$3.7M
Current Ratio
9.38
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: COVENANT LIVING
- Chain ID
168- Facilities in chain
- 15
- Legal business name
- COVENANT LIVING OF COLORADO
Chain-average star ratings (for peer context)
Overall
4.3
Health
4.0
Staffing
4.1
QM
3.7
Owner / manager organizations (1)
| Organization | Role | Association |
|---|---|---|
| COVENANT LIVING COMMUNITIES & SERVICES | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 01/26/1988 |
Owner / manager individuals (19)
| Name | Role | Association |
|---|---|---|
| HOLT, JODY | OPERATIONAL/MANAGERIAL CONTROL | since 06/02/2017 |
| BENTLEY, SARAH | CORPORATE DIRECTOR | since 07/01/2019 |
| CHRISTENSEN, PAMELA | CORPORATE DIRECTOR | since 07/01/2013 |
| DAVIS, KARA | CORPORATE DIRECTOR | since 07/01/2019 |
| EASTBURG, MARK | CORPORATE DIRECTOR | since 07/01/2019 |
| KINCANNON, KURT | CORPORATE DIRECTOR | since 07/01/2019 |
| MANLOVE, MATT | CORPORATE DIRECTOR | since 07/01/2017 |
| MARTIN, ROBERT | CORPORATE DIRECTOR | since 07/01/2019 |
| NELSON, RICHARD | CORPORATE DIRECTOR | since 07/01/2019 |
| OXENDALE, ROGER | CORPORATE DIRECTOR | since 07/01/2017 |
| RINARD, DALE | CORPORATE DIRECTOR | since 07/01/2019 |
| VANOVER, ANDREW | CORPORATE DIRECTOR | since 07/01/2019 |
| WENRICH, JOHN | CORPORATE DIRECTOR | since 07/01/2019 |
| CUNLIFFE, TERRI | CORPORATE OFFICER | since 05/22/2015 |
| ERICKSON, DAVID | CORPORATE OFFICER | since 01/31/2008 |
| ERICKSON, REBEKAH | CORPORATE OFFICER | since 07/01/2019 |
| HOLT, JODY | CORPORATE OFFICER | since 06/02/2017 |
| CUNLIFFE, TERRI | W-2 MANAGING EMPLOYEE | since 05/22/2015 |
| HOLT, JODY | W-2 MANAGING EMPLOYEE | since 06/02/2017 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- Yes
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
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.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $36 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 9.38 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 30.9% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 6.2% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-401,609 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $8,318,806 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 88.2% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -6.5% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $4,959,940 | metrics.total_assets |
| Cost Report | Total Costs ($) | $690,124 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $-3,693,340 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $8,653,280 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -4.8% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.80844 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.87231 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.91254 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 4.59329 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 4.02455 | 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 | 55.0 | 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 | 0.77765 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.11347 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.61296 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.50407 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.08847 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 4.0 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 4.3 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 3.7 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 4.1 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 168 | Chain ID |
| Provider Information | Chain Name | COVENANT LIVING | Chain Name |
| Provider Information | City/Town | WESTMINSTER | City/Town |
| Provider Information | CMS Certification Number (CCN) | 065367 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | Y | Continuing Care Retirement Community |
| Provider Information | County/Parish | Jefferson | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1998-03-25 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 4 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 39.8639 | Latitude |
| Provider Information | Legal Business Name | COVENANT LIVING OF COLORADO | Legal Business Name |
| Provider Information | Location | 9221 WADSWORTH PKWY,WESTMINSTER,CO,80021 | Location |
| Provider Information | Long-Stay QM Rating | 3 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -105.08 | 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 | 3 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 60 | 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 | 15 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.24134 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.90105 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 4 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Non profit - Church related | 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 | 9221 WADSWORTH PKWY | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | VILLAGE CARE AND REHABILITATION CENTER, THE | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 290 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 3 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 16 | 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 | 0 | 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 | 3 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2024-12-19 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 16 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 3 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 6 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2023-06-21 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 52 | 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 | 3 | 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 | 52 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 7 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.66767 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 61.5 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.56191 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.73372 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.60683 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.06420 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.82819 | 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 | 4.16874 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 2 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | 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 | 3034032900 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.65257 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 56.9 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 25.000 | 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 | 80021 | ZIP Code |