Cycle 1
Health 2024-08-15 · Fire 2024-08-15
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Highlands Ranch, CO
Continuing Care At Wind Crest
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3420 Mill Vista Rd, Highlands Ranch, CO
(303) 876-8349
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
44
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Erickson Senior Living
Operator or chain grouping
Approved since
2013-11-14
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 3 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
Hours and turnover
RN hours / resident day
1.71
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.02
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.34
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.42
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.18
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.71
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
955
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.71
Composite VBP score used to determine payment impact.
Payment multiplier
1.0167
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.75
Baseline 22.15% · Performance 18.95% · Measure score 5.75 · Achievement 5.35 · Improvement 5.75
Healthcare-associated infections
6.62
Baseline 6.94% · Performance 5.86% · Measure score 6.62 · Achievement 6.62 · Improvement 5.08
Total nurse turnover
4.07
Baseline 48.94% · Performance 47.06% · Measure score 4.07 · Achievement 4.07 · Improvement 0.28
Adjusted total nurse staffing
8.25
Baseline 4.34 hours · Performance 5.43 hours · Measure score 8.25 · Achievement 8.25 · Improvement 7.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 7.04% · Lower 95% interval 6.36% |
| Discharge to community | 59.52% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 59.09% · Lower 95% interval 48.7% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 16 · Denominator 36 |
| Discharge mobility score | 52.78% |
50.94%
1.8 pts better
|
Numerator 19 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 0% · Lower 95% interval 2.73% |
| Staff COVID-19 vaccination coverage | 70.79% |
8.2%
62.6 pts better
|
Numerator 63 · Denominator 89 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 69.44% |
56.45%
13 pts better
|
Numerator 25 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 47.62% |
25.2%
22.4 pts better
|
Numerator 10 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
93.5%
6.2 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 89.3% · Q3 77.8% · Q4 82.8% · 4Q avg 87.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
94.7%
3.3 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.4%
1.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
7.4%
5.6 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.0%
2.7 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
11.2%
0.1 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
20.6%
12.7 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% · 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 | 46.5% |
15.2%
31.3 pts worse
|
16.3%
30.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 39.5% |
14.6%
24.9 pts worse
|
14.9%
24.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.2% |
0.8%
6.4 pts worse
|
1.0%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 12.3% · Q3 6.2% · Q4 2.6% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.5%
1.9 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.6% · Q3 7.4% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
22.4%
5 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 8.5% · Q3 12.7% · Q4 30.1% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
3.7%
0.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 1.8% · Q4 8.9% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.1% |
76.4%
5.3 pts worse
|
81.7%
10.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 61.8% · Q3 61.3% · Q4 74.8% · 4Q avg 71.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.1% |
12.8%
8.3 pts worse
|
12.0%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 19.4% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
75.6%
17.7 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| 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 13.9% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-12-14 · Fire 2021-12-14
1 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-15
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 2024-10-09
E · Potential for more than minimal harm
2024-08-15
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-15
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 2024-10-09
E · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-09
E · Potential for more than minimal harm
2023-03-16
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-03-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-03-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-03-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-05-09
F · Potential for more than minimal harm
2021-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-26
F · Potential for more than minimal harm
2021-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-26
E · Potential for more than minimal harm
2021-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-14
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 2022-02-08
D · Potential for more than minimal harm
2021-12-14
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-02-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-15
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 2024-09-13
F · Potential for more than minimal harm
2023-03-16
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 2023-04-14
D · Potential for more than minimal harm
2023-03-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-16
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 2023-04-21
D · Potential for more than minimal harm
2023-03-16
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 2023-04-21
F · Potential for more than minimal harm
2021-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-04
Penalties and ownership
What sits behind the stars
Ownership
National Senior Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Oak Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Brown, Ian
Corporate Director · Individual
Brown, Patricia
Corporate Director · Individual
Butler, Richard
Operational/Managerial Control · Individual
Clupper, Katherine
Corporate Director · Individual
Colins, Mary
Corporate Director · Individual
Colins, Mary
Corporate Officer · Individual
Embley, Mark
Operational/Managerial Control · Individual
Embley, Mark
Corporate Officer · Individual
Erickson Senior Living LLC
Operational/Managerial Control · Organization
Erstad, Eileen
Corporate Director · Individual
Erstad, Eileen
Corporate Officer · Individual
Gantert, Neal
Operational/Managerial Control · Individual
Gantert, Neal
Corporate Officer · Individual
Hall, John
Operational/Managerial Control · Individual
Hall, John
Corporate Officer · Individual
Hong, Nantida
Operational/Managerial Control · Individual
Jacque, Zina
Corporate Director · Individual
Leonard, Monty
Corporate Director · Individual
Moscato, Mary
Corporate Director · Individual
National Senior Communities, Inc
Operational/Managerial Control · Organization
Paulk, Pamela
Corporate Director · Individual
Pomeranz, William
Corporate Director · Individual
Pomeranz, William
Corporate Officer · Individual
Rainbolt, Nicole
Operational/Managerial Control · Individual
Reel, Stephanie
Corporate Director · Individual
Roskiewicz, Michael
Corporate Director · Individual
Sawicki, Scott
Corporate Officer · Individual
Sharp, Russel
Corporate Director · Individual
Stiner, Pamela
Operational/Managerial Control · Individual
Stiner, Pamela
Corporate Officer · Individual
Sweetser, Christian
Operational/Managerial Control · Individual
Tyler, Daniel
Corporate Officer · Individual
Wallick, Daniel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Littleton
Littleton, CO
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Littleton Care And Rehabilitation Center
Littleton, CO
4-star overall rating with 4-star inspections with $7,781 in total fines with 3 recent health deficiencies
#3
Vi At Highlands Ranch Skilled Nursing
Highlands Ranch, CO
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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