Cycle 1
Health 2023-10-26 · Fire 2023-10-26
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Aurora, CO
Beth Israel At Shalom Park
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
14800 E Belleview Dr, Aurora, CO
(303) 680-5000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
140
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-09-08
CMS approved date
Coverage
Medicare + Medicaid
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
0.71
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.89
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.37
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
11%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
298
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0242
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Performance 18.38% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.83
Baseline 4.13 hours · Performance 4.45 hours · Measure score 4.83 · Achievement 4.83 · Improvement 1.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.22% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 14.81% · Lower 95% interval 7.2% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 24.71% |
8.2%
16.5 pts better
|
Numerator 64 · Denominator 259 |
| Staff flu vaccination coverage | 93.26% |
42%
51.3 pts better
|
Numerator 249 · Denominator 267 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
93.5%
5.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 99.3% · Q3 100.0% · Q4 99.3% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
94.7%
4.9 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.4%
2.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.1% · Q3 1.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
7.4%
6.3 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.5% · Q3 1.5% · Q4 0.8% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.0%
About the same
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.6% · Q3 4.8% · Q4 2.4% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
11.2%
0.9 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 9.6% · Q3 10.3% · Q4 8.8% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
20.6%
1.2 pts better
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 21.4% · Q3 19.8% · Q4 13.2% · 4Q avg 19.4% · 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 | 6.2% |
15.2%
9 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.7% · Q3 6.6% · Q4 4.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
14.6%
11 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 1.7% · Q3 5.1% · Q4 0.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.5%
1.3 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.2% |
22.4%
6.2 pts better
|
19.8%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 29.2% · Q3 24.9% · Q4 1.5% · 4Q avg 16.2% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
3.7%
1.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.4% · Q3 1.2% · Q4 0.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.0% |
76.4%
8.4 pts worse
|
81.7%
13.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 68.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-13 · Fire 2022-07-13
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2021-04-29 · Fire 2021-04-29
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-26
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-22
F · Potential for more than minimal harm
2023-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-07-13
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2022-08-02
E · Potential for more than minimal harm
2022-07-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-19
B · Minimal harm
2022-07-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-09-11
F · Potential for more than minimal harm
2021-04-29
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-04-29
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-04-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-06-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-07-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-10
E · Potential for more than minimal harm
2022-07-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-20
E · Potential for more than minimal harm
2021-04-29
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 2021-06-08
E · Potential for more than minimal harm
2021-04-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-04-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-08
Penalties and ownership
What sits behind the stars
Ownership
Moskowitz, Mindy
Operational/Managerial Control · Individual
Moskowitz, Mindy
Corporate Officer · Individual
Penner, Marc
Operational/Managerial Control · Individual
Penner, Marc
Corporate Director · Individual
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#2
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Brookdale Greenwood Village
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3-star overall rating with 2-star inspections with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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