Heights Care & Rehabilitation LLC
3131 S FEDERAL BLVD, DENVER, CO 80236
Below federal staffing minimum — average inspection record.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
|
0.55 ✗ Below federal minimum (0.55) |
|
Health Deficiencies
Violations found during federal inspections over the last 3 years.
|
23 |
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★★★ (5/5)
Staffing: ★★★☆☆ (3/5)
|
|
NursingHomeGrade Score
|
51/100 |
Data last updated: April 12, 2026
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
Most recent inspection (January 11, 2024)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected March 18, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 30, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 18, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2024
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2024
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 7, 2024
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 7, 2024
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 2, 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.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 6, 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.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 7, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 22, 2025
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 18, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 18, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 18, 2024
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024
Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 2, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 2, 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 13, 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 18, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2024
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2024
Inspection cycle 2 (September 16, 2022)
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected November 23, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 29, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 14, 2022
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2022
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 14, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 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.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 14, 2022
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 14, 2022
Inspection cycle 3 (August 16, 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.
Administration Deficiencies — Deficient, Provider has date of correction, corrected September 8, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 4, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 23, 2019
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 23, 2019
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 23, 2019
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 1, 2024
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 8, 2023
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 23, 2019
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.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 23, 2019
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 6, 2020
Ensure the activities program is directed by a qualified professional.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 15, 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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 4, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 8, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 8, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 23, 2019
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 1, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 23, 2019
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 1, 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 8, 2023
Quality Assurance & Integrity
NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.
Learn about our data methodology →Nearby facilities in DENVER
Compare local nursing homes using the same CMS-backed grading method.
UPTOWN CARE CENTER
SUITES AT CLERMONT PARK CARE CENTER, THE
HALLMARK NURSING CENTER
BRIARWOOD HEALTH CARE CENTER
Need help choosing a facility?
Get free guidance from senior living advisors. We may earn a referral fee from comparison services, but never from nursing facilities and never in ways that affect grades.
Compare nearby options → Get free help →Get score alerts for this facility
We'll email you when Heights Care & Rehabilitation LLC's staffing score changes.