VILLAGE CARE AND REHABILITATION CENTER, THE
Open-data reference.
VILLAGE CARE AND REHABILITATION CENTER, THE is a non profit - church related facility in WESTMINSTER, CO with 60 certified beds and a 4-star overall CMS rating. The facility has 23 deficiency records on file.
9221 WADSWORTH PKWY, WESTMINSTER, CO 80021
Phone: 3034032900
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 065367
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 60
- Residents
- 55
- In Hospital
- No
- County
- Jefferson
- Last Inspection
- Dec 19, 2024
Staffing Data
- RN Hours
- 0.83 (nat'l avg: 0.68)
- LPN Hours
- 0.73
- CNA Hours
- 2.61
- Total Nursing Hours
- 4.17 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 56.9%
- RN Turnover
- 61.5%
What the CMS Record Reveals About VILLAGE CARE AND REHABILITATION CENTER, THE
VILLAGE CARE AND REHABILITATION CENTER, THE operates 60 certified beds in WESTMINSTER, CO with approximately 55 residents currently in care, and carries a CMS overall rating of 4 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 (4★), staffing levels (4★), and quality measures (3★). 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 23 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.17 total nursing hours per resident day (national average 3.89), with RN coverage at 0.83 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, VILLAGE CARE AND REHABILITATION CENTER, THE 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 56.9%, 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 (23 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 6, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Jan 8, 2025
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 7, 2025
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: Nov 5, 2024
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: Jul 14, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Jul 24, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 27, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 7, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 28, 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: Jul 21, 2023
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: Mar 16, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Mar 13, 2023
Have 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.
Category: Administration Deficiencies
Corrected: Mar 20, 2023
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: Mar 22, 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: Mar 16, 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: Mar 22, 2023
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 7, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Mar 16, 2023
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: Oct 11, 2019
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.
Category: Environmental Deficiencies
Corrected: Oct 11, 2019
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: Oct 11, 2019
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 11, 2019
Assure that each resident’s assessment is updated at least once every 3 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 11, 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 | 29.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 8.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 4.8% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.7% | 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 | 2.6% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 82.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 62.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 35.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 11.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 88.6% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 60.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.6% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 24.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 5.7% | Yes |
Penalty History
| Date | Type | Amount |
|---|---|---|
| Feb 28, 2023 | Fine | $23K |
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for VILLAGE CARE AND REHABILITATION CENTER, THE?
What are the staffing levels at VILLAGE CARE AND REHABILITATION CENTER, THE?
How many beds does VILLAGE CARE AND REHABILITATION CENTER, THE have?
Does VILLAGE CARE AND REHABILITATION CENTER, THE have any deficiencies on record?
Has VILLAGE CARE AND REHABILITATION CENTER, THE received any fines or penalties?
Who owns VILLAGE CARE AND REHABILITATION CENTER, THE?
When was VILLAGE CARE AND REHABILITATION CENTER, THE last inspected?
What quality measures are tracked for VILLAGE CARE AND REHABILITATION CENTER, THE?
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.