01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-04-11 | 6 | 2024-04-11 | 13 |
| Cycle 2 | 2022-12-15 | 6 | 2022-12-15 | 4 |
| Cycle 3 | 2021-09-02 | 0 | 2021-09-02 | 8 |
CMS CCN 0652122026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Westlake Health And Rehabilitation Center
1637 29Th Ave Pl · Greeley, CO 80634 · Weld County
Certified beds107CMS provider file
Recent citation rows37current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-06-25 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-07-07 · complaint2025-04-07 · HEALTHF0760Severity J · isolated immediate jeopardy
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Past Non-Compliance · 2025-03-21 · complaint2024-10-16 · HEALTHF0921Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2024-11-01 · complaint2024-04-11 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-11 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-11 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-11 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-11 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-11 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-05-032024-04-11 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0231Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Provide large enough exits.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0341Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Waiver has been granted · 2024-11-012024-04-11 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Waiver has been granted · 2024-11-022024-04-11 · FIREK0712Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0753Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0781Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0911Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Correction field: Deficient, Provider has date of correction · 2024-07-012024-04-11 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2024-07-012022-12-15 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2023-01-272022-12-15 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Correction field: Deficient, Provider has date of correction · 2023-01-2703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-04-07 | Fine | $14,069 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CONLEY, CALVINIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2025
- FRASER, MALCOLMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/01/2024
- JORGENSEN, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/24/2024
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/24/2024
- GRAHAM, JOSEPHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/24/2024
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- SATO, AMIIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/09/2024
- NURSA INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- ONSHIFT INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- CONLEY, CALVINIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2025
- FRASER, MALCOLMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- PORT, BARRYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 06/21/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- SMV GREELEY CENTENNIAL LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2025
- CONLEY, CALVINIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/21/2025
- FRASER, MALCOLMIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/21/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.01per resident day
RN hours0.69per resident day
Weekend nurse hours2.67per resident day
Staff turnover72.3%CMS reported field
06 / LOCAL RECORDS
Open the Greeley ledger →Other published facilities nearby
Broadview Health And Rehabilitation Center100 beds · CMS overall 4/545 citation rowsCenter At Centerplace, Llc, The54 beds · CMS overall 2/536 citation rowsFairacres Manor, Inc.116 beds · CMS overall 4/536 citation rowsGrace Pointe Cont Care Sr Campus, Skilled Nursing53 beds · CMS overall 5/519 citation rowsLife Care Center Of Greeley124 beds · CMS overall 5/513 citation rows