Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SILVER HEIGHTS SKILLED NURSING AND REHABILITATION
CASTLE ROCK, CO · 91 certified beds · Last Life Safety survey April 3, 2025
CMS Certification Number 065285 · first certified December 1990
Ownership
Operated by MADISON CREEK PARTNERS · For profit - Limited Liability company
- Ownership changed September 15, 2021 (change of ownership)from CASTLE ROCK SENIOR LIVING LLC
Position within CO
28 citations — more than 84% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to April 2027. This facility’s last Life Safety survey was April 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index
- F-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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 28 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 21, 2022 | 9 |
| October 19, 2023 | 6 |
| April 3, 2025 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 3 | 2025-04-03 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-04-03 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-04-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-04-03 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-04-03 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2025-04-03 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2025-04-03 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2023-10-19 |
What the citations cover
- Smoke Deficiencies 16
- Egress Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Egress Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 3, 2025 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 16, 2025) |
October 19, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0231 | Provide large enough exits. | Waiver has been granted (April 30, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (June 30, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (April 30, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 13, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 13, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 13, 2023) |
July 21, 2022 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Past Non-Compliance (July 21, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 27, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 21, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (December 31, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 21, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 21, 2022) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (September 21, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.