Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HIGHLINE POST ACUTE
DENVER, CO · 125 certified beds · Last Life Safety survey August 15, 2024
CMS Certification Number 065256 · first certified April 1989
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- Ownership changed February 1, 2023 (change of ownership)from SEQUOIA CARE COMMUNITY, LLC
Position within CO
39 citations — more than 97% 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 19 citations; the earlier surveys in the window averaged 13. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (January 2026 to August 2026). Most CO facilities have been surveyed by October 2026. This facility’s last Life Safety survey was August 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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8 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.
Emergency preparedness
1 of the 39 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 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 39 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-0908 Keep all essential equipment working safely.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 | 39 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 21, 2019 | 9 |
| March 9, 2023 | 11 |
| August 15, 2024 | 19 |
| August 15, 2024 | 19 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-08-15 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-08-15 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-08-15 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 2 | 2023-03-09 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-08-15 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2023-03-09 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-08-15 |
| K-0271 | Have exits that are accessible at all times. | 2 | 2024-08-15 |
What the citations cover
- Smoke Deficiencies 16
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 7
- Miscellaneous Deficiencies 4
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 7 |
| Miscellaneous Deficiencies | 4 |
| Services Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 15, 2024 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 30, 2024) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (September 17, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 1, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 23, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (September 16, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Waiver has been granted (November 1, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (September 16, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 16, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (January 21, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 20, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 1, 2024) |
March 9, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 11, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 7, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 5, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 5, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 5, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 7, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 5, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 5, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 7, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (April 7, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 7, 2023) |
November 21, 2019 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (December 27, 2019) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 16, 2019) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 16, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 16, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 16, 2020) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 24, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 20, 2019) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (December 16, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 16, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.