Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holly Heights Care And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program, resulting in ongoing mouse activity in multiple resident rooms and hallways. A resident’s representative reported repeated sightings of mice and mouse droppings in a resident’s dresser, clothing, and bed, and personally cleaned and laundered the affected items after submitting multiple grievances. The NHA delayed action after the initial grievance and arranged for a pest control contractor that implemented a trapping plan limited to one unit, despite staff and residents on other units reporting frequent mouse sightings. A pest control specialist confirmed a delay between contract signing and trap placement and restricted the initial mitigation to one side of the building, while residents and staff described mice being caught in bathrooms, rooms, dirty clothes bins, and running in hallways on other units, and a live mouse was directly observed under a resident’s bed during the survey.
The facility did not inform several residents or their representatives about hospice care options before sharing their information with a hospice agency. Instead, the hospice agency contacted the families directly, causing confusion and concern. Staff interviews confirmed that the expected process was not followed, and documentation of prior discussions was lacking.
Three shower rooms were found to be unsanitary, with surveyors observing dirty towels, empty bottles, debris, and strong odors. A resident's representative reported seeing feces and unclean conditions in the shower area. Staff interviews revealed inconsistent cleaning practices, with CNAs and housekeepers not maintaining the expected level of cleanliness.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, or serve food according to professional standards, as observed by surveyors.
Surveyors identified that the facility did not maintain a safe and functional environment, as evidenced by a leaking kitchen handwashing sink with water collecting in a bucket and multiple damaged handrails throughout the building. The maintenance director reported ongoing issues with both the sink and handrails, including repeated leaks and persistent damage from resident contact, resulting in hazards such as exposed sharp edges and missing sections.
A resident's personal funds account was not reimbursed to the estate within the required timeframe after death. The facility failed to use the correct contact information available in the admission agreement, sent a refund check to an outdated address, and did not make further attempts to contact the representative, resulting in the estate not receiving the funds.
A resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors was able to leave the facility unnoticed when the front desk was briefly unattended. The absence was not discovered for several hours, and the resident was later found at a hospital with multiple abrasions after traveling several miles on foot.
A resident with severe cognitive impairments and dependent on staff for bathing did not receive scheduled showers during their stay. Despite facility policies requiring documentation of shower refusals, there was no record of the resident receiving or refusing showers. Staff interviews confirmed the lack of documentation, and the DON acknowledged the issue, noting the resident's wife's concerns about the need for forced showers.
The facility failed to provide individualized recreational activities for three residents, as outlined in their care plans. Despite the need for one-on-one visits to support their well-being, no such visits were documented over several months. The Activity Director admitted to not completing these visits, and the administration was aware but had not implemented corrective measures.
Failure to Maintain Effective Pest Control Across All Units
Penalty
Summary
The facility failed to maintain an effective pest control program to keep resident rooms free from mice on two of three units. The facility’s pest control policy required an environment free of pests, frequent contracted treatments, allowance for additional visits when problems were detected, and prompt reporting of pest control problems by staff. Despite this, a grievance submitted at the end of December documented mouse feces in a resident’s dresser drawers and on the resident’s clothes and bed, with the resident’s representative personally cleaning the drawers and taking clothes home to wash. The representative reported seeing mice frequently in the resident’s room and stated that there were no traps in the room as of a few days prior to the interview, and that management had provided little to no response despite multiple grievances. The NHA acknowledged receiving the written grievance about mice several days after it was filed and did not initiate housekeeping inspection of the affected unit until nearly a week after the grievance date. The NHA reported that the pest control company had previously been visiting only once per month and that an additional extermination contract was signed later, after the grievance, with the pest control company assessing the building and determining that mice were present only on one of three units. The pest control specialist confirmed that although the contract for extra work was signed, there was about a one‑week delay before traps were actually set, and that the initial mitigation plan and trap placement were limited to a single unit (rooms four through 30) on one side of the building. The specialist also stated that he had identified likely entry points near heater and air conditioner units but had not yet communicated these locations to the NHA. Multiple residents and staff reported ongoing mouse activity outside the unit initially targeted by the pest control plan. One resident reported a mouse caught in her bathroom and another reported a mouse caught in her room, both on a different unit than the one included in the initial mitigation plan, and stated that mice remained a problem throughout the facility despite frequent complaints. During an interview with one of these residents, a live mouse was observed under the resident’s bed, stuck on a glue board and squealing, and the NHA removed it from the room. Additional staff interviews revealed that a housekeeper had found a live mouse in a dirty clothes bin on that same hallway the previous week, a CNA had found and discarded a mouse in the same resident’s room, and an RN reported seeing mice a couple of times per week on her unit, with each sighting entered into the computer system for maintenance. Other residents reported often seeing several mice running up and down the hallway at night and “a lot of mice” in the hallway, including many mice seen just the prior week, demonstrating that mice activity was occurring on more than one unit while the facility’s pest control efforts remained limited and delayed.
Failure to Inform Residents or Representatives Prior to Hospice Referral
Penalty
Summary
The facility failed to inform four residents or their representatives about hospice care options prior to sharing their information with a hospice agency. According to the facility's Resident Rights policy, residents are to be fully informed in advance about care and treatment options and participate in planning their medical treatment. However, for four residents with severe cognitive impairments and complex medical conditions, there was no documentation in their electronic medical records indicating that the facility had discussed hospice services with them or their powers of attorney before the hospice agency was contacted. Interviews with the residents' representatives revealed that they were first contacted by the hospice agency, not the facility, regarding hospice services. These representatives expressed confusion and concern about how the hospice agency obtained their contact information and were disturbed by the unexpected nature of the calls, especially given the sensitive topic of end-of-life care. In some cases, representatives believed the calls could be attempts at financial abuse or posed a risk to the residents' safety, as they had not previously discussed hospice care with the facility. Staff interviews confirmed that the interdisciplinary team (IDT) identified residents who might benefit from hospice and that the facility's process should involve notifying residents or their representatives before contacting hospice providers. Nursing staff and the DON acknowledged that the facility did not always communicate with families prior to involving hospice agencies, and that this was a lapse in procedure. The hospice director also stated that families should be educated by the facility first, but admitted to being the initial point of contact for many families.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
Surveyors observed that three out of four shower rooms in the facility were not maintained in a safe, clean, and sanitary condition. Specific findings included empty shampoo and body wash bottles, piles of wet towels, and a strong smell of urine in one shower room. The inside of tubs contained bags of wet towels, empty bottles, black grime, hair, and unidentified trash. In another shower room, resident equipment such as wheelchairs, walkers, and bedside commodes blocked access to the shower stall. These conditions were directly observed by surveyors during their inspection. Interviews with a resident representative revealed that she had previously observed feces on the floor and in the shower, along with used towels and empty bottles left behind, resulting in a very bad odor. Staff interviews indicated inconsistent cleaning practices, with CNAs expected to clean after each use and housekeepers to deep clean weekly. The DON stated that tubs were not currently in use, but if a resident requested a bath, the tub would need to be checked and cleaned first. Despite these expectations, the observed conditions showed that the shower rooms were not being kept clean and sanitary as required.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Maintain Safe and Functional Environment Due to Leaking Kitchen Sink and Damaged Handrails
Penalty
Summary
The facility failed to maintain a safe, sanitary, functional, and comfortable environment for residents, staff, and the public. During an initial walk-through of the kitchen, a leaking P-trap pipe was observed under the handwashing sink, with water collecting in a nearly full three-gallon bucket. Staff interviews revealed conflicting accounts regarding the duration of the leak, with a dietary aide stating it began that week, while the maintenance director indicated the issue had persisted for several months, including leakage into the subfloor. The maintenance director also reported that a replacement P-trap pipe began leaking again about a month prior to the observation. Additionally, the facility failed to ensure that handrails were in safe, operational, and functional condition. Observations showed that several handrails in the facility were covered with gray electrical tape and yellow caution tape, had cracked sections with exposed sharp edges, and in some areas, the curved connecting sections were missing entirely. The maintenance director was unable to specify how long the handrails had been damaged and acknowledged that the damage was an ongoing issue due to residents bumping into the handrails, which created hazards for residents.
Failure to Timely Reimburse Resident Funds to Estate After Death
Penalty
Summary
The facility failed to accurately manage and reimburse the personal funds account of a resident after the resident's death. The resident's representative had opened a trust account upon admission, and the resident passed away before any funds were used. Despite the representative's repeated attempts to contact the facility regarding the refund, there was no documentation in the electronic medical record indicating that the facility had attempted to return the funds or contact the representative after the resident's death. The admission agreement contained the correct contact information, but the face sheet had an incorrect phone number for the representative. The business office manager initially stated that the resident did not have an account, but later confirmed the account existed and said a refund check would be sent. The facility sent a check to an old address, which was returned, and made no further attempts to contact the representative, despite having the correct information in the admission agreement. This resulted in the resident's estate not being reimbursed within 30 days as required.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident assessed as high risk for elopement. The resident, who had diagnoses including Wernicke's encephalopathy, repeated falls, unspecified dementia, somnolence, and alcohol dependence, was known to exhibit exit-seeking behaviors and had verbalized a desire to leave the facility. Despite being identified as a high elopement risk and having a care plan in place, the resident was able to leave the facility unnoticed through the front door. On the day of the incident, the resident exited the building at 3:42 p.m. without staff awareness. The absence was not discovered until approximately two hours later, at which point staff initiated a search inside and outside the facility. The local police, the nursing home administrator, and the director of nursing were notified several hours after the resident's disappearance. The resident was ultimately found at a hospital emergency room nearly ten hours after leaving the facility, having traveled approximately five miles and sustaining abrasions to multiple areas of the body. Interviews and record reviews confirmed that the resident had a history of severe cognitive impairment, frequent wandering, and behavioral disturbances, including agitation and restlessness. The resident had previously demonstrated exit-seeking behavior by pushing on the front door and had required one-to-one supervision at times. On the day of the elopement, the front desk receptionist, whose duties included monitoring the front door, was temporarily away from the desk assisting ambulance workers, during which time the resident left the facility. The facility's failure to maintain adequate supervision and monitoring directly resulted in the resident's elopement and subsequent injuries.
Failure to Document and Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for bathing, received his scheduled showers. The resident, who was over 65 years old and had severe cognitive impairments, was admitted for respite care and had a diagnosis of unsteadiness on his feet, repeated falls, and unspecified dementia. Despite being dependent on staff for showering, there was no documentation to confirm that the resident received or refused showers during his stay from October 9 to October 16, 2024. Interviews with staff revealed that if a resident refused a shower, it was supposed to be reported to the unit manager and documented in the progress notes. However, there was no evidence that this procedure was followed for the resident in question. The Director of Nursing acknowledged that there was no documentation of shower refusals and mentioned that the resident's wife had expressed concerns about the resident needing to be forced to shower. The lack of documentation and adherence to the facility's policy resulted in the failure to provide necessary services for the resident's personal hygiene.
Failure to Provide Individualized Recreational Activities
Penalty
Summary
The facility failed to provide person-centered, individualized recreational activities to meet the needs and interests of three residents, as identified in their comprehensive care plans. These residents were supposed to receive one-on-one activity visits to promote their physical, medical, and psychosocial well-being. However, the facility did not document any such visits for these residents, indicating a lack of adherence to the care plans. Resident #3, who had moderate cognitive impairments and required maximum assistance with daily activities, was identified as needing one-on-one activity visits two to three times per week. Despite this, there was no documentation of any such visits over a six-month period. Similarly, Resident #6, who was cognitively intact but had quadriplegia, was supposed to receive one-on-one visits to discuss current events and reminisce about his travels. He reported not having attended any group activities or received one-on-one visits for over nine months. Resident #8, with moderate cognitive impairment and various physical limitations, was also supposed to receive one-on-one visits focusing on leisure education and games. However, only two visits were documented over a six-month period. The Activity Director admitted to not completing or documenting these visits, acknowledging a failure to follow the residents' care plans. The facility's administration was aware of the issue but had not implemented a performance improvement plan to address the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highline Post Acute | 0 mi | — | 1 | 1 |
| Brookshire Post Acute | 0.6 mi | — | 3 | 1 |
| Amberwood Post Acute | 0.6 mi | — | 4 | 0 |
| Rowan Community, Inc | 0.7 mi | — | 3 | 0 |
| Suites At Clermont Park Care Center, The | 1.1 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.