Westlake Health and Rehabilitation Center

Name: Westlake Health and Rehabilitation Center
Address: 1637 29TH AVE PL, Greeley, CO, 80634, US
Telephone: 9703568181

1637 29th Ave Pl, Greeley, CO 80634 · Weld County · 107 certified beds · avg 90 residents/day · certified since Jul 1, 1985

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

4/5

Health inspection rating (on-site)

Serious findings on record

$14,069

Fines, last 3 years

3.06

Nurse hours/resident/day (adjusted)

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

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

⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.

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 · Apr 7, 2025 · F-0760 · triggered by a complaint

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.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

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: Mar 21, 2025 (Past Non-Compliance)

All citations in the current public record (12)

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 25, 2025	D · Potential for harm, one-off	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
Apr 7, 2025	▲ J · Immediate jeopardy, one-off	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
Oct 16, 2024	F · Potential for harm, facility-wide	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Apr 11, 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.
Apr 11, 2024	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Apr 11, 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.
Apr 11, 2024	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.
Apr 11, 2024	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.
Apr 11, 2024	D · Potential for harm, one-off	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.
Dec 15, 2022	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Dec 15, 2022	D · Potential for harm, one-off	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 15, 2022	D · Potential for harm, one-off	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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 6).

Year	Citations	Serious (G–L)	Worst severity that year
2022	3	0	E
2024	7	0	F
2025	2	1	J ▲

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 $14,069.

Date	Type	Amount / length
Apr 7, 2025	Fine	$14,069

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)	3.06	3.89	3.95	bottom 14% in Colorado; bottom 16% in the U.S.
Registered Nurse hours	0.71	0.86	0.69	bottom 37% in Colorado; top 36% in the U.S.
Weekend total nurse staffing	2.71	3.44	3.50	bottom 13% in Colorado; bottom 17% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.68	0.61	0.48	top 33% in Colorado; top 17% in the U.S.
Total nursing staff turnover (%)	72.3	47.1	45.8	bottom 4% in Colorado; bottom 4% in the U.S.
RN turnover (%)	61.5	44.6	42.9	bottom 17% in Colorado; bottom 20% 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 3.01, RN 0.69, weekend 2.67. 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: 3/5 · long-stay residents: 5/5 · short-stay residents: 2/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	05/24/2024
Conley, Calvin	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/01/2025
Conley, Calvin	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2025
Conley, Calvin	Individual	ADP of the SNF	NOT APPLICABLE	06/21/2025
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	09/01/2024
Fraser, Malcolm	Individual	Managing Control - Governing Body	NOT APPLICABLE	09/01/2024
Fraser, Malcolm	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2024
Fraser, Malcolm	Individual	ADP of the SNF	NOT APPLICABLE	06/21/2025
Graham, Joseph	Individual	Corporate Officer	NOT APPLICABLE	05/24/2024
Jorgensen, David	Individual	Corporate Director	NOT APPLICABLE	05/24/2024
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Nursa INC	Organization	Operational/Managerial Control	NOT APPLICABLE	09/01/2024
Onshift INC	Organization	Operational/Managerial Control	NOT APPLICABLE	09/01/2024
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	06/21/2025
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024
SMV Greeley Centennial LLC	Organization	ADP of the SNF	NOT APPLICABLE	09/01/2025

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 systems do you use to prevent medication errors, and what happens when one occurs?"
"Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
"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
Broadview Health and Rehabilitation Center	1.0 mi	Greeley, CO	★★★★☆	4/5
Fairacres Manor, INC.	1.1 mi	Greeley, CO	★★★★☆	4/5
Center at Centerplace, LLC, the	1.6 mi	Greeley, CO	★★☆☆☆	2/5
Life Care Center of Greeley	1.9 mi	Greeley, CO	★★★★★	4/5
Grace Pointe Cont Care Sr Campus, Skilled Nursing	3.2 mi	Greeley, CO	★★★★★	4/5
Pelican Pointe Health and Rehabilitation Center	9.9 mi	Windsor, CO	★☆☆☆☆	1/5
Columbine Commons Health and Rehab LLC	11.5 mi	Windsor, CO	★★★★★	5/5
Green House Homes at Mirasol, the	17.4 mi	Loveland, CO	★★★★★	4/5
Good Samaritan - Loveland Village	18.6 mi	Loveland, CO	★★★☆☆	2/5	abuse
Lemay Avenue Health and Rehab LLC	18.9 mi	Fort Collins, CO	★★★★☆	4/5
Riverbend Health and Rehabilitation Center	19.0 mi	Loveland, CO	★★☆☆☆	2/5	abuse
North Shore Health & Rehab Facility	19.5 mi	Loveland, CO	★★★★☆	4/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 065212.

The Care File

Visit checklist — Westlake Health and Rehabilitation Center

1637 29th Ave Pl, Greeley, CO 80634 · 9703568181

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $14,069

Most serious findings on record:

▲ Apr 7, 2025 (F-0760, Immediate jeopardy, one-off): 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.

Questions for the administrator:

☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
☐ "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 065212 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)