Cycle 1
Health 2024-03-28 · Fire 2024-03-28
18 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Greenwood Village, CO
Brookdale Greenwood Village
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
6450 S Boston St, Greenwood Village, CO
(303) 224-9455
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2000-08-14
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
1.07
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,158
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.37
Composite VBP score used to determine payment impact.
Payment multiplier
1.0057
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.58
Baseline 29.04% · Performance 18.14% · Measure score 8.58 · Achievement 7.10 · Improvement 8.58
Healthcare-associated infections
4.84
Baseline 7.18% · Performance 6.39% · Measure score 4.84 · Achievement 4.84 · Improvement 3.11
Total nurse turnover
4.27
Baseline 45.88% · Performance 46.24% · Measure score 4.27 · Achievement 4.27 · Improvement 0
Adjusted total nurse staffing
2.87
Baseline 4.25 hours · Performance 3.89 hours · Measure score 2.87 · Achievement 2.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.2% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 262 · Observed rate 7.63% · Lower 95% interval 6.81% |
| Discharge to community | 48.09% |
50.57%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 237 · Observed rate 43.46% · Lower 95% interval 41.94% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.07% |
95.27%
8.2 pts worse
|
Numerator 128 · Denominator 147 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 147 |
| Discharge self-care score | 52% |
53.69%
1.7 pts worse
|
Numerator 65 · Denominator 125 |
| Discharge mobility score | 59.2% |
50.94%
8.3 pts better
|
Numerator 74 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 2.74% |
2.29%
0.5 pts worse
|
Numerator 4 · Denominator 146 · Adjusted rate 2.83% |
| Healthcare-associated infections requiring hospitalization | 6.39% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 5.33% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 4.94% |
8.2%
3.3 pts worse
|
Numerator 8 · Denominator 162 |
| Staff flu vaccination coverage | 97.44% |
42%
55.4 pts better
|
Numerator 304 · Denominator 312 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 75 · Denominator 125 |
| Transfer of health information to provider | 91.67% |
95.95%
4.3 pts worse
|
Numerator 22 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 101 · Denominator 101 |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 18 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
93.5%
2.3 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 100.0% · Q3 96.6% · Q4 92.6% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.3% |
94.7%
11.4 pts worse
|
95.5%
12.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.4%
0.8 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 6.9% · Q4 3.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
7.4%
7.4 pts better
|
11.4%
11.4 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 who lose too much weight | 5.3% |
5.0%
0.3 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 12.0% · Q3 0.0% · Q4 4.3% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.1% |
11.2%
8.1 pts better
|
19.6%
16.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.0% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
20.6%
7.9 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q4 13.6% · 4Q avg 12.7% · 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 need for help with daily activities has increased | 5.2% |
14.6%
9.4 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.8%
0.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.5%
0.2 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 3.4% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
22.4%
1.2 pts worse
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 12.3% · Q3 34.8% · Q4 9.6% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
3.7%
0.9 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.6% · Q3 4.2% · Q4 2.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.5% |
76.4%
10.9 pts worse
|
81.7%
16.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.5% · Q2 62.7% · Q3 71.2% · Q4 67.5% · 4Q avg 65.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
12.8%
0.8 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.9% · Q3 0.8% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.5% |
75.6%
20.1 pts worse
|
79.7%
24.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
20.3%
5.2 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 14.0% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-21 · Fire 2022-12-21
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-08-31 · Fire 2021-08-31
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-09
F · Potential for more than minimal harm
2024-03-28
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-06-09
F · Potential for more than minimal harm
2024-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-09
F · Potential for more than minimal harm
2022-12-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-21
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 2023-02-10
F · Potential for more than minimal harm
2022-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-10
F · Potential for more than minimal harm
2021-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-13
D · Potential for more than minimal harm
2021-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-08-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-23
D · Potential for more than minimal harm
2021-08-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-01
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 2025-12-02
D · Potential for more than minimal harm
2025-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-12-01
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 2025-12-02
D · Potential for more than minimal harm
2025-12-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-02
E · Potential for more than minimal harm
2024-03-28
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-03-28
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 2024-04-29
E · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-28
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-28
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 2024-04-29
D · Potential for more than minimal harm
2024-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-28
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-28
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 2024-04-29
D · Potential for more than minimal harm
2024-03-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-28
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 2024-04-29
D · Potential for more than minimal harm
2024-03-28
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-29
C · Minimal harm
2024-03-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
D · Potential for more than minimal harm
2022-12-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-03-09
D · Potential for more than minimal harm
2022-12-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-07
D · Potential for more than minimal harm
2022-12-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-31
E · Potential for more than minimal harm
2021-08-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-08
E · Potential for more than minimal harm
2021-08-31
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 2021-10-08
E · Potential for more than minimal harm
2021-08-31
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-08-31
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-08-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-08-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-08-31
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 2021-10-08
Penalties and ownership
What sits behind the stars
Ownership
American Retirement Corporation
5% Or Greater Direct Ownership Interest · Organization
Brookdale Senior Living Inc
5% Or Greater Indirect Ownership Interest · Organization
Ally Bank
5% Or Greater Security Interest · Organization
Damask, Jeanne
Operational/Managerial Control · Individual
Houston, Tabetha
Operational/Managerial Control · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
Kussow, Dawn
Corporate Officer · Individual
La Marre, Kevin
Operational/Managerial Control · Individual
La Marre, Kevin
Corporate Officer · Individual
Leisure, Raymond
Operational/Managerial Control · Individual
Leisure, Raymond
Corporate Director · Individual
Leisure, Raymond
Corporate Officer · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Munoz, Anna
Corporate Officer · Individual
Reddy, Vikas
Operational/Managerial Control · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
Stengle, Nikolas
Corporate Director · Individual
Stengle, Nikolas
Corporate Officer · Individual
Vining, Heather
Operational/Managerial Control · Individual
White, Chadwick
Operational/Managerial Control · Individual
White, Chadwick
Corporate Director · Individual
White, Chadwick
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Suites At Holly Creek Care Center, The
Centennial, CO
5-star overall rating with 4-star inspections with $42,056 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Orchard Park Health Care Center
Littleton, CO
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Suites At Someren Glen Care Center, The
Centennial, CO
3-star overall rating with 3-star inspections with $36,446 in total fines with 8 recent health deficiencies
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