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CITY SCAPE REHABILITATION & CARE CENTER LLC

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CITY SCAPE REHABILITATION & CARE CENTER LLC is a for profit - partnership facility in DENVER, CO with 60 certified beds and a 2-star overall CMS rating. The facility has 36 deficiency records on file. Total penalties: $81K.

3345 FOREST ST, DENVER, CO 80207

Phone: 3033937600

Overall Rating

2/5

Health Inspection

1/5

Staffing

3/5

Quality Measures

5/5

Long-Stay Quality

5/5

Facility Information

Provider Number
065387
Ownership
For profit - Partnership
Provider Type
Medicare and Medicaid
Beds
60
Residents
58
In Hospital
No
County
Denver
Last Inspection
Jul 16, 2024
Abuse citation on record

Staffing Data

RN Hours
0.72 (nat'l avg: 0.68)
LPN Hours
0.47
CNA Hours
2.64
Total Nursing Hours
3.83 (nat'l avg: 3.89)
PT Hours
0.02

What the CMS Record Reveals About CITY SCAPE REHABILITATION & CARE CENTER LLC

CITY SCAPE REHABILITATION & CARE CENTER LLC operates 60 certified beds in DENVER, CO with approximately 58 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (3★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 36 deficiency records from recent surveys, of which 6 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $81K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.83 total nursing hours per resident day (national average 3.89), with RN coverage at 0.72 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Partnership" ownership and operating as a "Medicare and Medicaid" provider, CITY SCAPE REHABILITATION & CARE CENTER LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (36 most recent)

G — Isolated - Actual harm Jul 1, 2025 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: Jul 2, 2025

G — Isolated - Actual harm Jul 1, 2025 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jul 2, 2025

D — Isolated - Minimal harm May 1, 2025 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Jul 16, 2024 Tag: 0623

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Category: Resident Rights Deficiencies

Corrected: Aug 9, 2024

G — Isolated - Actual harm Jul 16, 2024 Tag: 0622

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Category: Resident Rights Deficiencies

Corrected: Aug 9, 2024

E — Pattern - Minimal harm Jul 16, 2024 Tag: 0947

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Category: Nursing and Physician Services Deficiencies

Corrected: Aug 9, 2024

E — Pattern - Minimal harm Jul 16, 2024 Tag: 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Category: Environmental Deficiencies

Corrected: Aug 9, 2024

E — Pattern - Minimal harm Jul 16, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Aug 9, 2024

D — Isolated - Minimal harm Jul 16, 2024 Tag: 0849

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Category: Administration Deficiencies

Corrected: Aug 9, 2024

D — Isolated - Minimal harm Jul 16, 2024 Tag: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Aug 9, 2024

E — Pattern - Minimal harm Jul 16, 2024 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Aug 9, 2024

D — Isolated - Minimal harm Jul 16, 2024 Tag: 0759

Ensure medication error rates are not 5 percent or greater.

Category: Pharmacy Service Deficiencies

Corrected: Aug 9, 2024

E — Pattern - Minimal harm Jul 16, 2024 Tag: 0730

Observe each nurse aide's job performance and give regular training.

Category: Nursing and Physician Services Deficiencies

Corrected: Aug 9, 2024

D — Isolated - Minimal harm Jul 16, 2024 Tag: 0656

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Aug 9, 2024

G — Isolated - Actual harm Jul 16, 2024 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Aug 9, 2024

C — Widespread - No harm Jul 16, 2024 Tag: 0575

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Category: Resident Rights Deficiencies

Corrected: Aug 9, 2024

E — Pattern - Minimal harm Nov 30, 2023 Tag: 0680

Ensure the activities program is directed by a qualified professional.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 10, 2024

D — Isolated - Minimal harm Nov 30, 2023 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jan 10, 2024

G — Isolated - Actual harm Mar 2, 2023 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

G — Isolated - Actual harm Mar 2, 2023 Tag: 0686

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

F — Widespread - Minimal harm Mar 2, 2023 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Mar 24, 2023

D — Isolated - Minimal harm Mar 2, 2023 Tag: 0790

Provide routine and 24-hour emergency dental care for each resident.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

F — Widespread - Minimal harm Mar 2, 2023 Tag: 0730

Observe each nurse aide's job performance and give regular training.

Category: Nursing and Physician Services Deficiencies

Corrected: Mar 25, 2023

D — Isolated - Minimal harm Mar 2, 2023 Tag: 0697

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

D — Isolated - Minimal harm Mar 2, 2023 Tag: 0685

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

D — Isolated - Minimal harm Mar 2, 2023 Tag: 0684

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

E — Pattern - Minimal harm Mar 2, 2023 Tag: 0679

Provide activities to meet all resident's needs.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

E — Pattern - Minimal harm Mar 2, 2023 Tag: 0678

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2023

D — Isolated - Minimal harm Mar 2, 2023 Tag: 0657

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Mar 25, 2023

D — Isolated - Minimal harm Dec 2, 2021 Tag: 0825

Provide or get specialized rehabilitative services as required for a resident.

Category: Quality of Life and Care Deficiencies

Corrected: Dec 31, 2021

E — Pattern - Minimal harm Dec 2, 2021 Tag: 0744

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

Category: Quality of Life and Care Deficiencies

Corrected: Dec 31, 2021

D — Isolated - Minimal harm Dec 2, 2021 Tag: 0695

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

Category: Quality of Life and Care Deficiencies

Corrected: Dec 31, 2021

E — Pattern - Minimal harm Dec 2, 2021 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Dec 31, 2021

E — Pattern - Minimal harm Dec 2, 2021 Tag: 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.

Category: Resident Rights Deficiencies

Corrected: Dec 31, 2021

D — Isolated - Minimal harm Dec 2, 2021 Tag: 0561

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Category: Resident Rights Deficiencies

Corrected: Dec 31, 2021

E — Pattern - Minimal harm Dec 2, 2021 Tag: 0550

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

Category: Resident Rights Deficiencies

Corrected: Dec 31, 2021

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 13.7% Yes
Percentage of long-stay residents who lose too much weight Long Stay 3.8% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.5% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 0.0% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 2.9% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 85.1% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 67.4% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay N/A Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 9.0% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 12.6% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 94.4% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay N/A No
Percentage of long-stay residents with pressure ulcers Long Stay 2.1% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 20.8% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 23.8% Yes

Penalty History 2 penalties totaling $81K

Date Type Amount
Jul 1, 2025 Fine $60K
Jul 16, 2024 Fine $20K
Mar 2, 2023 Fine $16K

Frequently Asked Questions

What is the overall CMS rating for CITY SCAPE REHABILITATION & CARE CENTER LLC?
CITY SCAPE REHABILITATION & CARE CENTER LLC has an overall CMS rating of 2 out of 5 stars. This rating combines health inspection results (1★), staffing levels (3★), and quality measures (5★).
What are the staffing levels at CITY SCAPE REHABILITATION & CARE CENTER LLC?
CITY SCAPE REHABILITATION & CARE CENTER LLC reports 3.83 total nursing hours per resident day (national average: 3.89). RN hours are 0.72 per resident day (national average: 0.68).
How many beds does CITY SCAPE REHABILITATION & CARE CENTER LLC have?
CITY SCAPE REHABILITATION & CARE CENTER LLC has 60 certified beds with approximately 58 residents. The facility is located at 3345 FOREST ST, DENVER, CO 80207.
Does CITY SCAPE REHABILITATION & CARE CENTER LLC have any deficiencies on record?
Yes, CITY SCAPE REHABILITATION & CARE CENTER LLC has 36 deficiencies on record from recent inspections. Of these, 6 are classified as causing actual harm or jeopardy.
Has CITY SCAPE REHABILITATION & CARE CENTER LLC received any fines or penalties?
Yes, CITY SCAPE REHABILITATION & CARE CENTER LLC has received 2 penalties totaling $81K.
Who owns CITY SCAPE REHABILITATION & CARE CENTER LLC?
CITY SCAPE REHABILITATION & CARE CENTER LLC is classified as "For profit - Partnership" ownership. The facility type is "Medicare and Medicaid".
When was CITY SCAPE REHABILITATION & CARE CENTER LLC last inspected?
The most recent health inspection for CITY SCAPE REHABILITATION & CARE CENTER LLC was on Jul 16, 2024. The facility received a health inspection rating of 1 out of 5 stars.
What quality measures are tracked for CITY SCAPE REHABILITATION & CARE CENTER LLC?
CITY SCAPE REHABILITATION & CARE CENTER LLC is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial