Mapleton Post Acute

Name: Mapleton Post Acute
Address: 115 INGALLS ST, Lakewood, CO, 80226, US
Telephone: 3032371325

115 Ingalls St, Lakewood, CO 80226 · Jefferson County · 90 certified beds · avg 76 residents/day · certified since Apr 1, 1968

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.57

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

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)

▲ Actual harm, one-off · Mar 19, 2024 · F-0697 · triggered by a complaint

The facility did not provide safe and appropriate pain management for a resident who needed it.

Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.

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: Apr 9, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (28)

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
Jun 17, 2025	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint
Jun 17, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Dec 5, 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.
Dec 5, 2024	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Dec 5, 2024	E · Potential for harm, repeated	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.
Dec 5, 2024	D · Potential for harm, one-off	The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint
Dec 5, 2024	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Mar 19, 2024	▲ G · Actual harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Mar 19, 2024	F · Potential for harm, facility-wide	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Mar 19, 2024	F · Potential for harm, facility-wide	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint
Jun 29, 2023	F · Potential for harm, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Jun 29, 2023	F · Potential for harm, facility-wide	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Jun 29, 2023	E · Potential for harm, repeated	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.
Jun 29, 2023	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Jun 29, 2023	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jun 29, 2023	E · Potential for harm, repeated	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.
Jun 29, 2023	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Jun 29, 2023	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jun 29, 2023	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.
Jun 29, 2023	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jun 29, 2023	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jun 29, 2023	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.
Jun 29, 2023	D · Potential for harm, one-off	The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Jun 29, 2023	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Aug 29, 2019	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 29, 2019	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Aug 29, 2019	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Aug 29, 2019	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (14 → 5).

Year	Citations	Serious (G–L)	Worst severity that year
2019	4	0	E
2023	14	0	F
2024	8	1	G ▲
2025	2	0	D

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)

No fines or payment denials in the published 3-year window.

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)	3.57	3.89	3.95	bottom 40% in Colorado; bottom 40% in the U.S.
Registered Nurse hours	0.63	0.86	0.69	bottom 29% in Colorado; top 44% in the U.S.
Weekend total nurse staffing	3.03	3.44	3.50	bottom 32% in Colorado; bottom 32% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.43	0.61	0.48	bottom 30% in Colorado; top 43% in the U.S.
Total nursing staff turnover (%)	50.0	47.1	45.8	bottom 41% in Colorado; bottom 38% in the U.S.
RN turnover (%)	55.6	44.6	42.9	bottom 27% in Colorado; bottom 28% 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 3.18, RN 0.56, weekend 2.70. 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
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	09/19/2022
Dunyon, David	Individual	Corporate Officer	NOT APPLICABLE	03/01/2023
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	09/19/2022
Garden Investment Co., LLC	Organization	ADP of the SNF	NOT APPLICABLE	03/01/2023
Horton, Christopher	Individual	Managing Control - Governing Body	NOT APPLICABLE	03/01/2023
Horton, Christopher	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2023
Horton, Christopher	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2023
Jorgensen, David	Individual	Corporate Director	NOT APPLICABLE	03/01/2023
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
McDonald, Dontre	Individual	Managing Control - Governing Body	NOT APPLICABLE	03/01/2023
McDonald, Dontre	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2023
McDonald, Dontre	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2023
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	09/05/2025
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you assess and manage residents' pain, especially for those who have trouble communicating?"
"Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"How do you prepare residents and families for discharge, and what support do you arrange for after they leave?"
"What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
"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
Oakwood Care and Rehabilitation	0.5 mi	Lakewood, CO	★☆☆☆☆	1/5	abuse
Sierra Post Acute	1.4 mi	Lakewood, CO	★★☆☆☆	1/5	abuse
Cedars Healthcare Center	1.6 mi	Lakewood, CO	★★★☆☆	2/5
Edgewater Health and Rehabilitation	1.7 mi	Lakewood, CO	★★★★★	4/5
Cambridge Care Center	1.7 mi	Lakewood, CO	★★★☆☆	2/5	abuse
Harmony Pointe Care Center	2.0 mi	Lakewood, CO	★★★☆☆	2/5
Villa Manor Care Center	2.2 mi	Lakewood, CO	★★★★☆	3/5
Western Hills Health Care Center	2.3 mi	Lakewood, CO	★★★☆☆	3/5
Sloan's Lake Rehabilitation Center	2.3 mi	Denver, CO	★★★★★	5/5
Allison Care Center	2.3 mi	Lakewood, CO	★★☆☆☆	2/5	abuse

Compare this facility with the 3 closest →

All facilities in Lakewood →

Facility data as of CMS processing date 2026-08-01. CCN 065097.

The Care File

Visit checklist — Mapleton Post Acute

115 Ingalls St, Lakewood, CO 80226 · 3032371325

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Most serious findings on record:

▲ Mar 19, 2024 (F-0697, Actual harm, one-off): The facility did not provide safe and appropriate pain management for a resident who needed it.

Questions for the administrator:

☐ "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
☐ "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "How do you prepare residents and families for discharge, and what support do you arrange for after they leave?"
☐ "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 065097 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)