Cycle 1
Health 2024-05-06 · Fire 2024-05-06
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Colorado Springs, CO
Bear Creek Senior Living
4-star overall rating with 4-star inspections with $6,614 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1685 S 21st St, Colorado Springs, CO
(719) 329-1774
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-12-02
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.21
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.70% · Performance 22.19% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.71
Baseline 6.04% · Performance 7.02% · Measure score 2.71 · Achievement 2.71 · Improvement 0
Total nurse turnover
4.27
Baseline 68.18% · Performance 47.50% · Measure score 4.27 · Achievement 3.96 · Improvement 4.27
Adjusted total nurse staffing
0.75
Baseline 4.25 hours · Performance 3.29 hours · Measure score 0.75 · Achievement 0.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.1% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 3.57% · Lower 95% interval 6.25% |
| Discharge to community | 62.17% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 71 · Observed rate 59.15% · Lower 95% interval 51.7% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 74.6% |
95.27%
20.7 pts worse
|
Numerator 47 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 62.16% |
53.69%
8.5 pts better
|
Numerator 23 · Denominator 37 |
| Discharge mobility score | 43.24% |
50.94%
7.7 pts worse
|
Numerator 16 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 1.78% |
| Healthcare-associated infections requiring hospitalization | 7.02% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 54.55% |
8.2%
46.3 pts better
|
Numerator 36 · Denominator 66 |
| Staff flu vaccination coverage | 95.52% |
42%
53.5 pts better
|
Numerator 64 · Denominator 67 |
| Discharge function score | 48.65% |
56.45%
7.8 pts worse
|
Numerator 18 · Denominator 37 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 5 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 72.2% |
93.5%
21.3 pts worse
|
93.4%
21.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 76.9% · Q3 69.6% · Q4 65.2% · 4Q avg 72.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
94.7%
5.8 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.2% |
3.4%
3.8 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 4.3% · Q4 17.4% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
7.4%
5.1 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
5.0%
4.2 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · Q4 15.0% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
11.2%
3.6 pts worse
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 17.4% · Q4 15.0% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
20.6%
6.5 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.9% |
15.2%
11.3 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
14.6%
8.5 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 40.9% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.8%
1.2 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.5%
0.7 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
22.4%
6.8 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 24.2% · Q3 22.3% · Q4 37.3% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
3.7%
2.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.1% |
76.4%
47.3 pts worse
|
81.7%
52.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 23.0% · Q3 28.8% · Q4 46.8% · 4Q avg 29.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
12.8%
3.6 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 16.7% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.2% · Q3 2.8% · Q4 1.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.6% |
75.6%
50 pts worse
|
79.7%
54.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
20.3%
9.8 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 27.8% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-26 · Fire 2023-01-26
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-12
F · Potential for more than minimal harm
2023-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-05
F · Potential for more than minimal harm
2023-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-01-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-01-26
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-05
F · Potential for more than minimal harm
2021-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-23
F · Potential for more than minimal harm
2021-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-10
F · Potential for more than minimal harm
2021-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-30
E · Potential for more than minimal harm
2021-11-04
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2021-12-30
D · Potential for more than minimal harm
2021-11-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-02-14
D · Potential for more than minimal harm
2021-11-04
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-12-21
D · Potential for more than minimal harm
2021-11-04
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-12-21
D · Potential for more than minimal harm
2021-11-04
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-03-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-30
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-03-07
F · Potential for more than minimal harm
2024-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-07
G · Actual harm
2023-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-02-21
G · Actual harm
2021-11-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-03
F · Potential for more than minimal harm
2021-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-11-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-12-03
Penalties and ownership
What sits behind the stars
$6,614
2025-01-30
Fine
Fine · fine $6,614
Fine
Ownership
Nearby options
Other facilities in reach
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Brookdale Skyline
Colorado Springs, CO
2-star overall rating with 3-star inspections with $15,088 in total fines with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Sundance Skilled Nursing And Rehabilitation
Colorado Springs, CO
5-star overall rating with 4-star inspections with $50,063 in total fines with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Kiowa Hills Rehabilitation And Nursing, LLC
Colorado Springs, CO
1-star overall rating with 1-star inspections with 21 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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