Eagle, CO
5-star overall rating with 4-star inspections with $9,565 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
195 Freestone Rd, Eagle, CO
(970) 989-2500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
44
Certified beds
Average residents
39
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Cassia
Operator or chain grouping
Approved since
2016-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 5 overall / 4 health / 5 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
RN hours / resident day
1.64
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.10
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.17
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.70
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.56
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.96
CMS adjusted RN staffing hours
Adjusted total hours
6.20
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
687
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.35
Composite VBP score used to determine payment impact.
Payment multiplier
1.0196
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
9.31
Baseline 18.99% · Performance 17.12% · Measure score 9.31 · Achievement 9.31 · Improvement 9
Healthcare-associated infections
7.91
Baseline 8.84% · Performance 5.61% · Measure score 7.91 · Achievement 7.46 · Improvement 7.91
Total nurse turnover
1.48
Baseline 81.54% · Performance 70.31% · Measure score 1.48 · Achievement 0 · Improvement 1.48
Adjusted total nurse staffing
7.44
Baseline 5.77 hours · Performance 5.19 hours · Measure score 7.44 · Achievement 7.44 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 5.65% · Lower 95% interval 6.72% |
| Discharge to community | 62.19% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 111 · Observed rate 69.37% · Lower 95% interval 55.12% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.63% |
95.27%
3.4 pts better
|
Numerator 72 · Denominator 73 |
| Falls with major injury | 2.74% |
0.77%
2 pts worse
|
Numerator 2 · Denominator 73 |
| Discharge self-care score | 74.24% |
53.69%
20.5 pts better
|
Numerator 49 · Denominator 66 |
| Discharge mobility score | 75.76% |
50.94%
24.8 pts better
|
Numerator 50 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 4.11% |
2.29%
1.8 pts worse
|
Numerator 3 · Denominator 73 · Adjusted rate 7.65% |
| Healthcare-associated infections requiring hospitalization | 5.61% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 0% · Lower 95% interval 3.02% |
| Staff COVID-19 vaccination coverage | 18.18% |
8.2%
10 pts better
|
Numerator 14 · Denominator 77 |
| Staff flu vaccination coverage | 42.73% |
42%
0.7 pts better
|
Numerator 47 · Denominator 110 |
| Discharge function score | 74.24% |
56.45%
17.8 pts better
|
Numerator 49 · Denominator 66 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.25% |
96.28%
2 pts better
|
Numerator 56 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 73.68% |
25.2%
48.5 pts better
|
Numerator 28 · Denominator 38 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
93.5%
1.2 pts better
|
93.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 94.3% · Q3 93.3% · Q4 93.9% · 4Q avg 94.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
94.7%
2.7 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.4%
1.9 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.7% · Q3 6.7% · Q4 0.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.7% |
7.4%
0.3 pts worse
|
11.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.7% · Q3 13.3% · Q4 9.7% · 4Q avg 7.7% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
5.0%
4.1 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
11.2%
0.7 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.0% · Q3 8.3% · Q4 9.7% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
20.6%
2.6 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 20.8% · Q3 21.7% · Q4 25.0% · 4Q avg 23.2% · 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 | 15.0% |
15.2%
0.2 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 12.4% · Q3 17.1% · Q4 13.0% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
14.6%
4.2 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 13.3% · Q3 8.3% · Q4 20.7% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.8%
1 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.5%
0.8 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 0.0% · Q4 3.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
22.4%
4.3 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 36.6% · Q3 20.3% · Q4 24.1% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 9.0% |
3.7%
5.3 pts worse
|
5.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 15.3% · Q3 4.8% · Q4 4.3% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
76.4%
13.1 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.2% · Q2 100.0% · Q3 92.1% · Q4 89.6% · 4Q avg 89.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
12.8%
3 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 2.4% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.0% |
75.6%
18.4 pts better
|
79.7%
14.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.8% |
20.3%
4.5 pts better
|
23.9%
8.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 13.5% · Expected 20.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-18
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-18
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-10-18
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-10-18
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-18
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-10-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-18
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-05-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-22
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-27
Inspection history
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-16
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-07-17
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-17
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-17
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-17
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-17
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-17
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-04-17
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-01-19
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-01-19
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2022-01-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-01-19
Health
Respond appropriately to all alleged violations.
Corrected 2022-01-19
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-01-19
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-01-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-01-19
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-01-19
Penalties and ownership
Fine · fine $9,565
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Nearby options
Carbondale, CO
2-star overall rating with 1-star inspections with $38,365 in total fines with 17 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Glenwood Springs, CO
2-star overall rating with 3-star inspections with $5,293 in total fines with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Rifle, CO
2-star overall rating with 1-star inspections with abuse icon flag with $32,975 in total fines with 11 recent health deficiencies
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