Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

HILLTOP PARK POST ACUTE

DENVER, CO · 162 certified beds · Last Life Safety survey March 7, 2024

CMS Certification Number 065241 · first certified August 1988

Ownership

Operated by PACS GROUP · For profit - Limited Liability company

  • Ownership changed September 1, 2023 (change of ownership)from 290 SOUTH MONACO PARKWAY OPERATIONS LLC
19
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

Position within CO

19 citations — more than 58% 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 8.5. 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 (August 2025 to March 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was March 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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Which alerts

1 inspection-and-testing tag has 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)

4 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 19 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-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

This facility19CO median16National median11
Citations on file over three years, compared
MeasureCitations
This facility19
Median facility in CO16
Median facility nationally11

Survey history

Citations at each Life Safety survey
92021-0882022-1222024-03
Citations at each Life Safety survey
Survey dateCitations
August 26, 20219
December 15, 20228
March 7, 20242

Most-cited tags

Most-cited tags at this facility
K-09182K-03251K-03741K-03241K-03551K-09231K-02711K-03711
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.22022-12-15
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.12021-08-26
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.12022-12-15
K-0324Provide properly protected cooking facilities.12022-12-15
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12022-12-15
K-0923Have proper medical gas storage and administration areas.12024-03-07
K-0271Have exits that are accessible at all times.12021-08-26
K-0371Have properly sized and located compartments to protect residents from smoke.12021-08-26

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 9
  • Egress Deficiencies 4
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Miscellaneous Deficiencies 2
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies9
Egress Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies3
Miscellaneous Deficiencies2
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 7, 2024 — 2 citations

Citations issued on March 7, 2024
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (April 26, 2024)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (April 26, 2024)

December 15, 2022 — 8 citations

Citations issued on December 15, 2022
TagWhat the surveyor checksStatus
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (April 3, 2023)
K-0331Construct fire resistant interior walls.Deficient, Provider has date of correction (January 27, 2023)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (February 7, 2023)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (January 27, 2023)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (March 2, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (February 6, 2023)
K-0781Have restrictions on the use of portable space heaters.Deficient, Provider has date of correction (February 6, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 25, 2023)

August 26, 2021 — 9 citations

Citations issued on August 26, 2021
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (December 6, 2021)
K-0227Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.Deficient, Provider has date of correction (December 6, 2021)
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (December 6, 2021)
K-0321Ensure 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 6, 2021)
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.Deficient, Provider has date of correction (December 6, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (December 15, 2021)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 6, 2021)
K-0371Have properly sized and located compartments to protect residents from smoke.Deficient, Provider has date of correction (December 6, 2021)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 6, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.