Hearth Record

Centura Health-St Anthony North Health Campus

An acute care hospital in Westminster, Colorado 80023

14300 Orchard Pkwy, Westminster, Colorado 80023. (720) 627-0000.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 1 deficiency in 1 month of the last 36. Last cited Oct 2025. Most serious: Standard-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.

What did inspectors find?

The last inspection on record was on Apr 27, 2026: a complaint inspection.

1 deficiency cited in the last three years.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

1 deficiency in 1 month of the last 36. Last cited Oct 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

1 deficiency by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Oct 1, 2025: complaint inspection1 deficiency

  • Patient Rights: Care In Safe Setting

    The inspectors’ words, 1,036 words

    “PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47959 Based on interviews and documents reviewed, the facility failed to ensure staff assessed and addressed patient pain levels according to facility policy in three of five obstetrical emergency department (OBED) patients reviewed. (Patients #1, #2, and #4) Findings include: Facility policy: The Pain Management policy read, pain was assessed upon admission, during and after any known pain-producing event, with each new report of pain and at least once a shift. Pain reassessment was done within two hours of pain interventions. 1. The facility failed to ensure staff assessed and addressed patient pain levels according to facility policy. a. A review of Patient #1’s medical record revealed Patient #1 delivered a baby on 12/22/24 at 2:30 a.m. at a community birth center and experienced a second degree perineal tear (a tear that extends through the muscles and skin of the perineum, the area between the vagina and anus). Patient #1 arrived by ambulance at the facility at 4:02 a.m. for delivery of a retained placenta (the placenta did not separate from the uterine wall following childbirth). The medical record revealed medical provider (MD) #1 performed a vaginal exam and evacuated 500 mL of clotted blood. The review revealed no evidence of a pain assessment performed or pain medication offered prior to the vaginal exam. The medical record also revealed staff followed the vaginal exam with an initial pain assessment at 4:20 a.m., which revealed Patient #1 had a 10/10 level of pain. Further review of Patient #1’s medical record revealed staff administered 100 mcg of fentanyl (a narcotic pain medication) at 4:21 a.m. MD #1 then performed a bimanual massage uterine sweep exam (a procedure done with the provider’s first hand inside the vagina and uterus while they put their second hand on the abdomen to push on the uterus). The medical record revealed staff medicated Patient #1 with 600 mg of ibuprofen (an anti-inflammatory pain medication) at 6:08 a.m. There was no evidence of a pain assessment performed after the administration of fentanyl, during or after the bimanual massage uterine sweep, or before the administration of ibuprofen. The review revealed staff performed the next pain assessment at 7:52 a.m., more than three hours after the pain producing event. Patient #1 left the facility against medical advice (AMA) at 9:35 a.m. This was in contrast to the Pain Management policy, which read, pain was assessed upon admission, during and after any known pain-producing event, and pain reassessment was done within two hours of pain interventions. b. A review of Patient #2’s medical record revealed Patient #2 arrived at the OBED on 3/10/25 at 8:15 p.m. after they experienced a mechanical fall while 38 weeks pregnant. The medical record revealed Patient #2 was discharged home at 9:53 p.m., with instructions to follow up with their doctor on 3/13/25, take acetaminophen (a pain medication) as needed, and apply a lidocaine adhesive patch (a topical pain reliever) every morning. The medical record revealed the medical provider had discussed Patient #2’s pain, however, staff did not perform a pain assessment or provide pain-relieving interventions to Patient #2 during their stay. c. A review of Patient #4’s medical record revealed Patient #4 was 33 weeks pregnant and arrived at the OBED on 9/14/25 at 10:44 p.m. with abdominal and back pain. The medical record revealed Patient #4 had a kidney stone and a urinary tract infection (UTI). Provider documentation revealed Patient #4 was instructed to take acetaminophen for pain. Patient #4 was discharged at 5:11 a.m. There was no evidence of a pain assessment or pain-relieving interventions provided to Patient #4 during their stay. Additionally, acetaminophen instructions were not included on Patient #4’s discharge instructions. The medical record reviews for Patients #2 and #4 were in contrast to the Pain Management policy, which read, pain was assessed upon admission, and during and after any known pain-producing event. d. Between 9/29/25 and 10/1/25, interviews conducted with staff revealed the following: i. In an interview with registered nurse (RN) #2, RN #2 stated a manual sweep for a retained placenta was uncomfortable and staff assessed for pain and administered fentanyl for patients in pain. RN #2 reviewed Patient #1’s monitoring strip from the medical record and stated Patient #1 was in pain on 12/22/24 at 4:17 a.m., as evidenced by an increase in Patient #1’s heart rate, which started at 80 beats/minute and went above 120 beats/minute. ii. In an interview with RN #4, RN #4 stated staff assessed pain upon arrival. RN #4 stated additional assessments were completed if the patient’s condition changed, or if the patient had pain producing procedures performed. RN #4 stated they reassessed patients within two hours of a pain management intervention per the facility’s pain management policy. RN #4 stated when staff did not manage patients’ pain, it caused additional trauma for the patient. iii. In an interview with MD #3, MD #3 stated they offered patients fentanyl for pain control for procedures related to retained placentas. MD #3 stated fentanyl took effect within a minute or two, and unless the patient hemorrhaged, they took the time to medicate patients for their comfort. MD #3 stated they wanted patients comfortable to support cooperation with the procedure, and to prevent unnecessary mental or emotional trauma from the experience. iv. In an interview with MD #1, MD #1 stated Patient #1’s placenta had started to release from the uterus and MD #1 continued to massage the uterus externally on Patient #1’s abdomen. MD #1 stated Patient #1 became uncomfortable, so they stopped the massage, administered fentanyl, and then resumed the bimanual sweep procedure. MD #1 stated they offered Patient #1 pain medication prior to the first vaginal exam, however, Patient #1 declined. MD #1 stated Patient #1 realized they needed pain medication for the procedure once MD #1 started the examination, so staff administered the fentanyl. This was in contrast to Patient #1’s medical record review, which revealed no evidence that staff assessed Patient #1’s pain, offered, or administered pain medication prior to the first vaginal exam according to facility policy.”

    Rule A0144. Standard-level. From a complaint.

All 8 inspections in the last three years
Inspections on record
DateVisitWhat the record says
Apr 27, 2026Complaint inspectionNo deficiencies cited
Jan 13, 2026Complaint inspectionNo deficiencies cited
Oct 1, 2025Complaint inspection1 deficiency cited
Mar 4, 2025Complaint inspectionNo deficiencies cited
Nov 26, 2024Complaint inspectionNo deficiencies cited
Jul 31, 2024Complaint inspectionNo deficiencies cited
Mar 5, 2024Complaint inspectionNo deficiencies cited
Nov 8, 2023Complaint inspectionNo deficiencies cited

How do patients fare?

  • CMS’s overall for it is 5 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 0 better and 0 worse of 6; safety of care, 2 better and 0 worse of 6; readmission, 3 better and 0 worse of 7.
  • Patients rate it 3 of 5 in CMS’s patient survey (927 surveys completed, Oct 1, 2024 to Sep 30, 2025): 70% rated it 9 or 10 out of 10, and 69% would definitely recommend it.
  • Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), better than the national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
  • CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
  • Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 10.5%, heart failure 12.1%, pneumonia 13.4%, COPD 9.5%, stroke 12.5%. CMS gives no comparison with the national rate for them in this release.
  • Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.3%, heart failure 20%, pneumonia 14.7%, COPD 19.3%, hip or knee replacement 5.6%. CMS gives no comparison with the national rate for them in this release.
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 160 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
  • 85% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
  • Medicare’s spending per patient here is 0.98 times the national median (Jan 1, 2024 to Dec 31, 2024).
Source:

CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.

CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 55 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 53 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Jan 1, 1991.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • Voluntary non-profit - Private.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
  • 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
  • In CMS’s patient survey, patients rate how well its nurses communicated 2 of 5.
  • 92% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • Commonspirit Health owns 100% directly since Apr 1, 2008.
  • Commonspirit Mountain Region runs it.
  • 20 owners or officers are people: Rogelio Segura (corporate director); Michelle Soriano (corporate director); Ryan Holocher (corporate director); Patricia Hayden (corporate director); Ryan Patrick Tobin (corporate director); Dana Talarico (corporate director); Mitch Melfi (corporate director); Tadd Richert (corporate officer); Tadd Richert (runs it (operational or managerial control)); David Perez (corporate director); Irene Lofland (corporate director); Sheri Shapiro (corporate director); Katherine Brooks (corporate officer); Matthew L Esson (corporate director); Jw Stamison (corporate director); Thomas G. Friermood (corporate director); Constance Schmidt (managing employee (on the payroll)); Andrew Gaasch (corporate officer); Andrew Gaasch (corporate director); Lisandra Gonzales (corporate director).
  • CMS’s Provider of Services file records no change of ownership.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
Commonspirit HealthOwns 5% or more directly100%Apr 1, 2008
Commonspirit Mountain RegionRuns it (operational or managerial control)Sep 11, 2006

How does it compare nearby?

  • No other hospital CMS lists is in Broomfield County.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.
  • In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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