Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CITY SCAPE REHABILITATION & CARE CENTER LLC
DENVER, CO · 60 certified beds · Last Life Safety survey July 16, 2024
CMS Certification Number 065387 · first certified October 2006
Ownership
Operated by SWEETWATER CARE · For profit - Partnership
- New ownershipOwnership changed May 16, 2025 (change of ownership)from FOREST STREET LTC, LLLP
Position within CO
10 citations — more than 30% 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 4 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to July 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was July 2024. 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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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 10 Life Safety citations above. The Physical Environment Index
- 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 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.
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 | 10 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 2, 2021 | 6 |
| March 2, 2023 | 0 |
| July 16, 2024 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-07-16 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2021-12-02 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2021-12-02 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2021-12-02 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2021-12-02 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-07-16 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2021-12-02 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2024-07-16 |
What the citations cover
- Smoke Deficiencies 6
- Egress Deficiencies 3
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 16, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 27, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 15, 2024) |
December 2, 2021 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (January 12, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 12, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 12, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 12, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Waiver has been granted (June 30, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.