Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HOLLY HEIGHTS CARE AND REHABILITATION
DENVER, CO · 133 certified beds · Last Life Safety survey August 21, 2025
CMS Certification Number 065124 · first certified October 1974
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
- Ownership changed August 1, 2024 (change of ownership)from HOLLY HEIGHTS NURSING HOME INC.
Position within CO
22 citations — more than 66% 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 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was August 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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3 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 22 Life Safety citations above. The Physical Environment Index
- 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.
- 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-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 | 22 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 14, 2022 | 6 |
| January 9, 2024 | 3 |
| August 21, 2025 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2025-08-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-08-21 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-08-21 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2025-08-21 |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 1 | 2025-08-21 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-08-21 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2025-08-21 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2025-08-21 |
What the citations cover
- Smoke Deficiencies 10
- Egress Deficiencies 6
- Services Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Egress Deficiencies | 6 |
| Services Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 21, 2025 — 13 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 (October 18, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (October 18, 2025) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (October 18, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 18, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 18, 2025) |
| 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 (October 18, 2025) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (October 18, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has plan of correction (October 18, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has plan of correction (April 18, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has plan of correction (April 18, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 18, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 18, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 7, 2025) |
January 9, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (February 8, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 30, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 4, 2024) |
September 14, 2022 — 6 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-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 19, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 11, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 5, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 21, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 13, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.