Cycle 1
Health 2025-04-17 · Fire 2025-04-17
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Services (3 deficiencies)
Colorado Springs, CO
Brookdale Skyline
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
2365 Patriot Hts, Colorado Springs, CO
(719) 667-5360
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2003-11-26
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
0.32
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
0.86
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
1.46
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
0.59
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
1.13
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
1.46
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,906
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0078
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 23.39% · Performance 16.90% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
6.05
Baseline 5.38% · Performance 6.03% · Measure score 6.05 · Achievement 6.05 · Improvement 0
Total nurse turnover
2.35
Baseline 62.74% · Performance 54.05% · Measure score 2.35 · Achievement 2.35 · Improvement 1.79
Adjusted total nurse staffing
2.84
Baseline 4.24 hours · Performance 3.89 hours · Measure score 2.84 · Achievement 2.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.86% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 4.93% · Lower 95% interval 6.4% |
| Discharge to community | 67.98% |
50.57%
17.4 pts better
|
Better than the National Rate · Eligible stays 123 · Observed rate 65.04% · Lower 95% interval 59.87% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 85% |
95.27%
10.3 pts worse
|
Numerator 102 · Denominator 120 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 120 |
| Discharge self-care score | 43.33% |
53.69%
10.4 pts worse
|
Numerator 39 · Denominator 90 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 30 · Denominator 90 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 120 · Adjusted rate 2.94% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 3.16% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 1.41% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 71 |
| Staff flu vaccination coverage | 90.75% |
42%
48.8 pts better
|
Numerator 157 · Denominator 173 |
| Discharge function score | 43.33% |
56.45%
13.1 pts worse
|
Numerator 39 · Denominator 90 |
| Transfer of health information to provider | 79.49% |
95.95%
16.5 pts worse
|
Numerator 62 · Denominator 78 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 35.09% |
25.2%
9.9 pts better
|
Numerator 20 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.3
0.9 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
93.5%
4.8 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.2% |
94.7%
3.5 pts worse
|
95.5%
4.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.4%
3.4 pts better
|
3.3%
3.3 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 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 | 6.2% |
5.0%
1.2 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.1% · Q3 7.4% · Q4 0.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
11.2%
About the same
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 10.7% · Q3 11.1% · Q4 9.1% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
20.6%
6.3 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 18.2% · Q3 13.6% · 4Q avg 14.3% · 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 | 26.9% |
14.6%
12.3 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 11.5% · Q3 40.0% · 4Q avg 26.9% · 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 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · 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 4.0% · Q2 0.0% · Q3 3.2% · 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 | 23.7% |
22.4%
1.3 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 14.2% · Q3 27.9% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
3.7%
1.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.4% · Q3 5.5% · Q4 6.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
76.4%
9.3 pts better
|
81.7%
4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.4% · Q2 85.7% · Q3 93.6% · Q4 87.9% · 4Q avg 85.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
12.8%
2.8 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.7% · Q3 1.2% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
75.6%
14.8 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
20.3%
3.9 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 21.4% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-06-22 · Fire 2022-06-22
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-04-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-04-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-04-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-04-17
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-04-17
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-08-13
F · Potential for more than minimal harm
2025-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-04-17
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 2025-06-20
F · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-20
F · Potential for more than minimal harm
2023-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-09
F · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-09
F · Potential for more than minimal harm
2023-08-31
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-11-09
F · Potential for more than minimal harm
2023-08-31
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 2023-11-09
F · Potential for more than minimal harm
2023-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-09
F · Potential for more than minimal harm
2022-06-22
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-07-22
F · Potential for more than minimal harm
2022-06-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-03
F · Potential for more than minimal harm
2022-06-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-06
F · Potential for more than minimal harm
2022-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-25
F · Potential for more than minimal harm
2022-06-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-25
F · Potential for more than minimal harm
2022-06-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-25
F · Potential for more than minimal harm
2022-06-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-25
F · Potential for more than minimal harm
2022-06-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-26
E · Potential for more than minimal harm
2022-06-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-25
E · Potential for more than minimal harm
2022-06-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-24
E · Potential for more than minimal harm
2022-06-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-25
E · Potential for more than minimal harm
2022-06-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-25
Inspection history
Recent health citations
G · Actual harm
2025-12-10
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.
Not marked corrected
E · Potential for more than minimal harm
2025-06-11
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 2025-07-17
F · Potential for more than minimal harm
2025-04-17
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-05-23
E · Potential for more than minimal harm
2023-08-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-31
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-31
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-31
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-09-22
G · Actual harm
2023-05-25
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 2023-05-26
G · Actual harm
2022-06-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-22
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 2022-07-22
D · Potential for more than minimal harm
2022-06-22
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-07-22
Penalties and ownership
What sits behind the stars
$14,015
2025-12-10
Fine
Fine · fine $14,015
Fine
$1,073
2023-05-25
Fine
Fine · fine $1,073
Fine
Ownership
Kussow, Dawn
Operational/Managerial Control · Individual
La Marre, Kevin
Operational/Managerial Control · Individual
Muhlbauer, Anneliese
Operational/Managerial Control · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Prudential Multifamily Mortgage LLC
5% Or Greater Security Interest · Organization
Prudential Multifamily Mortgage LLC
5% Or Greater Mortgage Interest · Organization
Reddy, Vikas
Operational/Managerial Control · Individual
Smith, Thomas
Corporate Director · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
White, Chadwick
Operational/Managerial Control · Individual
Whitley, Matthew
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Bear Creek Senior Living
Colorado Springs, CO
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
#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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