Heights Care & Rehabilitation LLC
Open-data reference.
Heights Care & Rehabilitation LLC is a for profit - limited liability company facility in DENVER, CO with 110 certified beds and a 2-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $78K.
3131 S FEDERAL BLVD, DENVER, CO 80236
Phone: 3037610260
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 065191
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 110
- Residents
- 73
- In Hospital
- No
- County
- Denver
- Last Inspection
- Jan 11, 2024
Staffing Data
- RN Hours
- 0.55 (nat'l avg: 0.68)
- LPN Hours
- 0.82
- CNA Hours
- 1.81
- Total Nursing Hours
- 3.18 (nat'l avg: 3.89)
- PT Hours
- 0.07
- Nursing Turnover
- 67.5%
- RN Turnover
- 57.1%
What the CMS Record Reveals About Heights Care & Rehabilitation LLC
Heights Care & Rehabilitation LLC operates 110 certified beds in DENVER, CO with approximately 73 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 50 deficiency records from recent surveys, of which 5 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 3 penalties totaling $78K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.18 total nursing hours per resident day (national average 3.89), with RN coverage at 0.55 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Heights Care & Rehabilitation 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. Reported nursing turnover at this facility is 67.5%, above the level where continuity of care typically begins to suffer. 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 (50 most recent)
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: Dec 22, 2025
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: May 30, 2025
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 29, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 7, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 7, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 1, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Apr 1, 2024
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Category: Resident Rights Deficiencies
Corrected: Mar 13, 2024
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category: Resident Rights Deficiencies
Corrected: Feb 9, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Mar 13, 2024
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: Feb 7, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 7, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Mar 18, 2024
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 7, 2024
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 6, 2024
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 2, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 18, 2024
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 18, 2024
Provide 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.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 18, 2024
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 18, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Feb 9, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Feb 9, 2024
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: Mar 18, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Mar 18, 2024
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: Mar 13, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Feb 2, 2024
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category: Resident Rights Deficiencies
Corrected: Feb 2, 2024
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 11, 2023
Provide 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.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 4, 2023
Ensure the activities program is directed by a qualified professional.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 15, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 8, 2023
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Category: Administration Deficiencies
Corrected: Sep 8, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 8, 2023
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: Sep 8, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 8, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Sep 8, 2023
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 14, 2023
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 4, 2023
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Nov 23, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2022
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: Oct 14, 2022
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: Oct 14, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Oct 14, 2022
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: Oct 14, 2022
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 26, 2022
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: Oct 14, 2022
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Oct 14, 2022
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 23, 2019
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 4.3% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.6% | 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 | 1.6% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.1% | 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 | 1.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 96.8% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 76.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 7.4% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 10.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 8.5% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 75.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 8.1% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 21.3% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 22.6% | Yes |
Penalty History 3 penalties totaling $78K
| Date | Type | Amount |
|---|---|---|
| May 15, 2024 | Fine | $29K |
| Jan 11, 2024 | Fine | $39K |
| Jan 11, 2024 | Payment Denial | - |
| Jun 15, 2023 | Fine | $10K |
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Frequently Asked Questions
What is the overall CMS rating for Heights Care & Rehabilitation LLC?
What are the staffing levels at Heights Care & Rehabilitation LLC?
How many beds does Heights Care & Rehabilitation LLC have?
Does Heights Care & Rehabilitation LLC have any deficiencies on record?
Has Heights Care & Rehabilitation LLC received any fines or penalties?
Who owns Heights Care & Rehabilitation LLC?
When was Heights Care & Rehabilitation LLC last inspected?
What quality measures are tracked for Heights Care & Rehabilitation LLC?
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.
Read our methodology — how this data is sourced, computed, and verified.