Nursing Care Index

Brookshire Post Acute

Denver, Denver County, Colorado · CCN 065242 · For-profit (Individual) · part of Pacs Group (274 facilities, chain average 2.9 stars)

CMS rates Brookshire Post Acute 1 of 5 overall as of August 2026. 67 certified beds, 58 residents a day on average. 45 citations on record from the current inspection cycles, 2 at immediate jeopardy; 2 fines totalling $75,713 and 1 payment denial.

On record

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★★☆☆ 3 of 5
Quality measures★★★★☆ 4 of 5
Quality: long-stay / short-stay4 / — of 5

Staffing

Total nurse staffing3.27279 hours per resident per day
Registered nurses0.70684 hours per resident per day
Weekend total3.04961 hours per resident per day
Nursing staff turnover57.8% (registered nurses 61.5%)
Administrators who left1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-01-06
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-30
2025-10-16
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2025-11-13
2025-10-16
complaint survey
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-11-13
2025-01-16 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-02-14
2025-01-16 Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies · tag F0565
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-12
2025-01-16 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-14
2025-01-16 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-12
2025-01-16 Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Administration Deficiencies · tag F0940
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-14
2025-01-16 Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-07
2025-01-16 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · tag F0582
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-07
2025-01-16 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-14
2025-01-16
complaint survey
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · tag F0676
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-14
2025-01-16 Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · tag F0730
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-14
2025-01-16 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-07
2025-01-16
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-14
2024-01-25 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.
Resident Rights Deficiencies · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-15
2024-01-25 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-15
2024-01-25 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-15
2024-01-25 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0603
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies · tag F0685
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Quality of Life and Care Deficiencies · tag F0742
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2024-01-25 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-15
2023-10-12
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-08
2023-10-12
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-13
2023-10-12
complaint survey
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · tag F0688
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-22
2023-10-12
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-22
2023-10-12
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-13
2023-10-12
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-13
2022-09-29 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2022-10-04
2022-09-29 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2022-10-04
2022-09-29 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0603
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-10-04
2022-09-29 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-10-04
2022-09-29 Ensure staff are vaccinated for COVID-19
Infection Control Deficiencies · tag F0888
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-10-04
2022-09-29 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-10-04
2022-09-29 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-10-04
2022-09-29 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-10-04
2022-09-29 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-10-04
2022-09-29 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Administration Deficiencies · tag F0849
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-10-04
2022-09-29 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-10-04

Fines and payment denials

DatePenaltyAmount
2025-10-16Fine$46,638
2023-10-12Payment denial for 12 days from 2023-11-10
2023-10-12Fine$29,075

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Centennial Master Tenant, LLC
Organization
5% or greater direct ownership interest100%2022-10-11
Providence Group Nh, LLC
Organization
5% or greater indirect ownership interest100%2023-06-30
Horton, Christopher
Individual
contracted managing employee2023-04-20
Apt, Frederick
Individual
corporate officer2024-01-01
Hancock, Mark
Individual
corporate officer2024-01-01
Jergensen, Joshua
Individual
corporate officer2024-01-01
Mitchell, John
Individual
corporate officer2024-01-01
Mbida, Zacharie
Individual
w-2 managing employee2023-11-27

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Denver County.