Holly Heights Care and Rehabilitation
6000 E Iliff Ave, Denver, CO 80222 · Denver County · 133 certified beds · avg 98 residents/day · certified since Oct 1, 1974
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 11, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 10, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Sep 14, 2022 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 7, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 21, 2026 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. · from a complaint |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 11, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 28, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 13, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Jan 9, 2024 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 9, 2024 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. · from a complaint |
| Jan 9, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 9, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jan 9, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. · from a complaint |
| Sep 14, 2022 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 14, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 2 | 1 | G ▲ |
| 2024 | 7 | 0 | F |
| 2025 | 13 | 1 | J ▲ |
| 2026 | 1 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $9,249.
| Date | Type | Amount / length |
|---|---|---|
| Jun 11, 2025 | Fine | $9,249 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.91 | 3.89 | 3.95 | bottom 9% in Colorado; bottom 11% in the U.S. |
| Registered Nurse hours | 0.51 | 0.86 | 0.69 | bottom 15% in Colorado; bottom 39% in the U.S. |
| Weekend total nurse staffing | 2.60 | 3.44 | 3.50 | bottom 10% in Colorado; bottom 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.41 | 0.61 | 0.48 | bottom 26% in Colorado; top 46% in the U.S. |
| Total nursing staff turnover (%) | 34.4 | 47.1 | 45.8 | top 18% in Colorado; top 23% in the U.S. |
| RN turnover (%) | 52.6 | 44.6 | 42.9 | bottom 33% in Colorado; bottom 32% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.92, RN 0.51, weekend 2.61. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Abbott, Swati | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Agwunobi, John | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Blouin, Ann | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 04/25/2024 |
| Burton, Spencer | Individual | Corporate Officer | NOT APPLICABLE | 04/25/2024 |
| Christensen, Christopher | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Graham, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 04/25/2024 |
| Horton, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 02/13/2025 |
| Hughes, Heath | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2024 |
| Hughes, Heath | Individual | ADP of the SNF | NOT APPLICABLE | 02/12/2025 |
| Jorgensen, David | Individual | Corporate Officer | NOT APPLICABLE | 04/25/2024 |
| Parkinson, Mark | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Port, Barry | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Port, Barry | Individual | Corporate Officer | NOT APPLICABLE | 04/25/2024 |
| Sato, Ami | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Shaw, Daren | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Smith, Barry | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Snapper, Suzanne | Individual | Corporate Director | NOT APPLICABLE | 04/25/2024 |
| Snapper, Suzanne | Individual | Corporate Officer | NOT APPLICABLE | 04/25/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "How do you explain health changes and treatment options to residents and their families?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What happens if a resident is hungry between meals or misses a mealtime — what food options are available?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Highline Post Acute | 0.0 mi | Denver, CO | ★☆☆☆☆ | 1/5 | |
| Brookshire Post Acute | 0.6 mi | Denver, CO | ★☆☆☆☆ | 1/5 | abuse |
| Amberwood Post Acute | 0.6 mi | Denver, CO | ★★☆☆☆ | 2/5 | |
| Rowan Community, INC | 0.7 mi | Denver, CO | ★★★★☆ | 2/5 | |
| Suites at Clermont Park Care Center, the | 1.1 mi | Denver, CO | ★★★★★ | 5/5 | |
| South Valley Post Acute Rehabilitation | 1.2 mi | Denver, CO | ★★★★☆ | 4/5 | |
| Crestmoor Care Center | 1.8 mi | Denver, CO | ★★★☆☆ | 2/5 | abuse |
| Berkley Manor Care Center | 2.0 mi | Denver, CO | ★★★★★ | 3/5 | |
| Hilltop Park Post Acute | 2.6 mi | Denver, CO | ★★☆☆☆ | 1/5 | |
| Julia Temple Healthcare Center | 3.0 mi | Englewood, CO | ★★★☆☆ | 3/5 | |
| Center at Lowry, LLC | 3.6 mi | Denver, CO | ★★★☆☆ | 2/5 | |
| Englewood Post Acute and Rehabilitation | 3.6 mi | Englewood, CO | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065124.