What is South Valley Post Acute Rehabilitation's Medicare star rating?

CMS rates South Valley Post Acute Rehabilitation 4 out of 5 stars overall, with 4 for health inspections, 2 for staffing and 4 for quality measures (CMS data as of September 1, 2026).

How many deficiencies did South Valley Post Acute Rehabilitation get at its last inspection?

7 health deficiencies at the standard inspection on January 29, 2026. The Colorado average is 8.7.

Has South Valley Post Acute Rehabilitation been fined?

CMS lists no fines in the last three years.

Does South Valley Post Acute Rehabilitation accept Medicaid?

It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.

Who owns South Valley Post Acute Rehabilitation?

CMS lists 16 owners and managers, and links the home to The Ensign Group. Legal business name: AVALANCHE HEALTHCARE INC..

South Valley Post Acute Rehabilitation: Inspections

The record in brief

At its most recent standard inspection, on January 29, 2026, inspectors cited 7 health deficiencies (the Colorado average is 8.7, the national average 9.2).

None of its 11 health citations since September 2022 was rated as actual harm or immediate jeopardy.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.10 hours per resident per day, against 3.72 across Colorado and 3.86 nationally. Registered nurses accounted for 0.46 of those hours.

48.9% of nursing staff left within the year CMS measured (Colorado average 47.1%).

CMS links it to The Ensign Group, an affiliated group of 344 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

209/22

111/23

105/24

701/26

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 11 health citations on file.

Severity

Isolated

Pattern

Widespread

Immediate jeopardy

Actual harm

Potential for more than minimal harm

Potential for minimal harm

January 29, 2026Standard inspection, Complaint inspection · 7 citations

F

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · Past noncompliance: already fixed when inspectors found it

Inspectors wroteBased on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. Specifically, the facility did not designate an RN to serve as the DON on a full-time basis after the DON's RN license expired on [DATE].
E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 20, 2026

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for one of three shower rooms, 12 of 22 sample resident room sinks and one (#2) of four residents reviewed for accident hazards out of 52 sample residents. Specifically, the facility failed to:-Ensure the water in facility shower rooms had safe bathing temperatures and staff had adequate monitoring equipment; and,-Ensure certified nurse aide (CNA) #5 transferred Resident #2 appropriately, which resulted in a fall for the resident.
E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 20, 2026

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.
E

Provide and implement an infection prevention and control program.

F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 20, 2026

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfectingresident rooms and high-frequency touched areas (call lights, door handles and handrails); and,-Ensure urinary catheter tubing and collection bag were handled in a sanitary manner for Resident #100.
D

Allow residents to self-administer drugs if determined clinically appropriate.

F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2026

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#118) of 10 residents out of 52 sample residents. Specifically, the facility failed to ensure an assessment was conducted to determine whether the self-administration of medications was clinically appropriate for Resident #118.
D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2026

Inspectors wroteBased on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for two (#9 and #113) of seven residents reviewed for behavioral and emotional status out of 52 sample residents. Specifically, the facility failed to:-Identify and implement person-centered interventions after an assessed decline in mood and history of trauma for Resident #9; and,-Coordinate timely necessary behavioral, mental and emotional health care and services for Resident #113 after the resident expressed suicidal ideation.
D

Ensure medication error rates are not 5 percent or greater.

F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2026

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically the facility's medication error rate was 7.69%, or two errors out of 26 opportunities for error.

May 16, 2024Complaint inspection · 1 citation

D

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.

F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 15, 2024

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and sanitary homelike environment in one out of three units reviewed. Specifically, the facility failed to ensure the residents experienced a clean and sanitary homelike environment with living spaces free from odors, soiled and damaged floors and walls, chipped paint, clean living common area spaces and availability of clean linens.

November 13, 2023Standard inspection · 1 citation

D

Provide safe and appropriate respiratory care for a resident when needed.

F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 29, 2023

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#5) of two residents who required respiratory care received the care consistent with professional standards of practice out of 30 sample residents. Specifically, for Resident #5 the facility failed to: -Ensure a physician's order was in place for oxygen therapy; -Ensure a care plan was in place to include oxygen route, frequency, and liters required; and, -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments.

September 8, 2022Standard inspection · 2 citations

D

Allow residents to self-administer drugs if determined clinically appropriate.

F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 2, 2022

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that before a resident was allowed to self-administer medications, the interdisciplinary team (IDT) assessed the resident's ability to safely and accurately do so for 1 (Resident #402) of 1 sampled resident reviewed for self-administration of medications.
D

Provide safe and appropriate respiratory care for a resident when needed.

F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 2, 2022

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent potential complications for 1 (Resident #3) of 3 sampled residents reviewed for respiratory care.

Fire safety inspections

23 fire safety citations on file: 10 on January 29, 2026, 3 on November 13, 2023, 10 on September 8, 2022.

Every fire safety citation23 citations

F
Meet other general requirements.

K 100 · January 29, 2026 · deficient, provider has
F
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.

K 222 · January 29, 2026 · Corrected (the home has a date of correction)
F
Have properly located and lighted "Exit" signs.

K 293 · January 29, 2026 · Corrected (the home has a date of correction)
F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

K 321 · January 29, 2026 · Corrected (the home has a date of correction)
F
Have approved installation, maintenance and testing program for fire alarm systems.

K 345 · January 29, 2026 · Corrected (the home has a date of correction)
F
Inspect, test, and maintain automatic sprinkler systems.

K 353 · January 29, 2026 · Corrected (the home has a date of correction)
F
Properly select, install, inspect, or maintain portable fire extinguishes.

K 355 · January 29, 2026 · Corrected (the home has a date of correction)
F
Have properly installed electrical wiring and gas equipment.

K 511 · January 29, 2026 · Corrected (the home has a date of correction)
F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

K 521 · January 29, 2026 · Corrected (the home has a date of correction)
F
Have generator or other power source capable of supplying service within 10 seconds.

K 918 · January 29, 2026 · Corrected (the home has a date of correction)
F
Have properly installed electrical wiring and gas equipment.

K 511 · November 13, 2023 · Corrected (the home has a date of correction)
F
Have simulated fire drills held at unexpected times.

K 712 · November 13, 2023 · Corrected (the home has a date of correction)
F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

K 927 · November 13, 2023 · Corrected (the home has a date of correction)
F
Have approved installation, maintenance and testing program for fire alarm systems.

K 345 · September 8, 2022 · Corrected (the home has a date of correction)
F
Inspect, test, and maintain automatic sprinkler systems.

K 353 · September 8, 2022 · Waiver
F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

K 372 · September 8, 2022 · Corrected (the home has a date of correction)
F
Have simulated fire drills held at unexpected times.

K 712 · September 8, 2022 · Corrected (the home has a date of correction)
F
Have generator or other power source capable of supplying service within 10 seconds.

K 918 · September 8, 2022 · Waiver
F
Have proper medical gas storage and administration areas.

K 923 · September 8, 2022 · Corrected (the home has a date of correction)
E
Provide properly protected cooking facilities.

K 324 · September 8, 2022 · Corrected (the home has a date of correction)
E
Install corridor and hallway doors that block smoke.

K 363 · September 8, 2022 · Corrected (the home has a date of correction)
E
Have properly installed electrical wiring and gas equipment.

K 511 · September 8, 2022 · Corrected (the home has a date of correction)
E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

K 741 · September 8, 2022 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

Measure	This home	Colorado	United States
All nursing staff (RN, LPN and aides)	3.10	3.72	3.86
Registered nurses	0.46	0.82	0.69
All nursing staff on weekends	2.79	3.29	3.42
Nurse aides	2.01
Licensed practical nurses	0.63
Nursing staff turnover (share who left in a year)	48.9%	47.1%	45.8%
Registered nurse turnover	41.7%	44.6%	42.9%
Administrators who left	1

CMS expects 3.48 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.23 on weekdays and 2.79 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.27 in April to June 2025 to 3.10 in January to March 2026.

Quarter	All nursing staff	Registered nurses	Weekdays	Weekends	Contract staff share	Days with no RN hours	Residents a day
Jan to Mar 2026	3.10	0.46	3.23	2.79	0.0%	0 of 90	103
Oct to Dec 2025	3.22	0.53	3.33	2.93	0.1%	0 of 92	101
Jul to Sep 2025	3.28	0.52	3.40	2.98	0.1%	0 of 92	99
Apr to Jun 2025	3.27	0.54	3.39	2.98	0.0%	0 of 91	96
United States, Jan to Mar 2026	3.75	0.62	3.92	3.33	5.3%	0.5% of days
Colorado, Jan to Mar 2026	3.59	0.76	3.75	3.18	5.9%	0.2% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

Measure	This home	Colorado	US
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1	13.7	13.4	13.9
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1	0.3	0.6	0.8
Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1	0.9	1.4	1.6
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1	3.7	3.4	3.2
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1	0.8	1.6	1.6
Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1	13.7	13.3	14.1
Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1	4.7	3.4	4.6
Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1	10.7	20.0	15.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231	22.3	20.3	23.8
Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231	12.3	12.1	12.0
Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231	2.4	1.4	1.9
Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231	1.0	1.7	1.8

Owners and operators

Legal business name: AVALANCHE HEALTHCARE INC.. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.

Name	Role	Type	Share	Since
The Ensign Group, Inc.	5% or greater indirect ownership interest	Organization	100%	06/18/2014
Horton, Christopher	Managing control - governing body	Individual		04/01/2021
Wilson, Hunter	Managing control - governing body	Individual		04/01/2020
Jorgensen, David	Corporate director	Individual		12/15/2020
Burnam, Soon	Corporate officer	Individual		12/15/2020
Graham, Joseph	Corporate officer	Individual		09/20/2024
Keetch, Chad	Corporate officer	Individual		03/01/2011
Sato, Ami	Corporate officer	Individual		09/09/2024
Kare Technologies LLC	Operational/managerial control	Organization		04/01/2021
Horton, Christopher	Operational/managerial control	Individual		04/01/2021
Wilson, Hunter	Operational/managerial control	Individual		04/01/2020
Port, Barry	Individual is an owner, partner or trustee of any ADP of the SNF	Individual		06/21/2025
Ensign Services Inc	Adp of the SNF	Organization		12/15/2020
Smv Denver Red Rocks LLC	Adp of the SNF	Organization		04/01/2021
Horton, Christopher	Adp of the SNF	Individual		06/21/2025
Wilson, Hunter	Adp of the SNF	Individual		06/25/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 4 problems in this area, most recently on January 29, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 3 problems in this area, most recently on January 29, 2026: "Allow residents to self-administer drugs if determined clinically appropriate."
How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 2 problems in this area, most recently on January 29, 2026: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs."
How many nurses and aides work each shift, nights and weekends included?Inspectors cited 1 problem in this area, most recently on January 29, 2026: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis."
Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.79 hours per resident per day, below the Colorado average of 3.29.
How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

Rowan Community, Inc
Denver, 0.5 mi · 4 of 5 stars · 28 citations
Amberwood Post Acute
Denver, 0.6 mi · 2 of 5 stars · 39 citations
Brookshire Post Acute
Denver, 0.6 mi · 1 of 5 stars · 45 citations
Suites at Clermont Park Care Center, the
Denver, 0.7 mi · 5 of 5 stars · 13 citations
Holly Heights Care and Rehabilitation
Denver, 1.2 mi · 3 of 5 stars · 23 citations
Highline Post Acute
Denver, 1.2 mi · 1 of 5 stars · 36 citations
Crestmoor Care Center
Denver, 2 mi · 3 of 5 stars · 29 citations
Berkley Care Center
Denver, 2.2 mi · 5 of 5 stars · 29 citations

Colorado contacts for a concern about a nursing home

These are the official offices in Colorado. NursingHomeClear cannot take or act on complaints.

Inspections and complaints: Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Services Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
Resident advocate: Colorado State Long-Term Care Ombudsman Program, 303-862-3524. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
State inspection reports: Find and compare facilities, where Colorado publishes its own records on licensed homes.

Common questions

What is South Valley Post Acute Rehabilitation's Medicare star rating?: CMS rates South Valley Post Acute Rehabilitation 4 out of 5 stars overall, with 4 for health inspections, 2 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did South Valley Post Acute Rehabilitation get at its last inspection?: 7 health deficiencies at the standard inspection on January 29, 2026. The Colorado average is 8.7.
Has South Valley Post Acute Rehabilitation been fined?: CMS lists no fines in the last three years.
Does South Valley Post Acute Rehabilitation accept Medicaid?: It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns South Valley Post Acute Rehabilitation?: CMS lists 16 owners and managers, and links the home to The Ensign Group. Legal business name: AVALANCHE HEALTHCARE INC..

Sources

Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
Owners: CMS Ownership. Penalties: CMS Penalties.
Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.