13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Denver, CO
3-star overall rating with 2-star inspections with abuse icon flag with $845 in total fines with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
895 S Monaco Pkwy, Denver, CO
(303) 321-3110
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
108
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vivage Senior Living
Operator or chain grouping
Approved since
1991-04-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.84
Registered nurse staffing
LPN hours / resident day
0.35
Licensed practical nurse staffing
Aide hours / resident day
1.66
Nurse aide staffing
Weekend hours
2.52
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
22%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
93.5%
5.4 pts worse
|
93.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.4% |
94.7%
6.3 pts worse
|
95.5%
7.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.4%
0.2 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
7.4%
4.9 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.0%
1.5 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.2% |
11.2%
5 pts better
|
19.6%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
20.6%
1.3 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.9% |
15.2%
12.3 pts better
|
16.3%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
14.6%
11.5 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.5%
1.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.0% |
22.4%
15.4 pts better
|
19.8%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
3.7%
0.2 pts worse
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.0% |
76.4%
35.4 pts worse
|
81.7%
40.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 37.9% |
75.6%
37.7 pts worse
|
79.7%
41.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-10
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 2025-03-21
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-21
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 2025-03-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-10
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-10
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-27
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-04
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-27
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-27
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-27
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-27
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-27
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-14
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-04
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-14
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-14
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-09-14
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-09-14
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-14
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-09-14
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-09-14
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-03
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-17
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-17
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-17
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 2025-03-17
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-03-17
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-03-17
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-17
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 2025-03-17
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 2024-03-31
Health
Keep all essential equipment working safely.
Corrected 2024-03-31
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-06
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 2023-10-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-06
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-06
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-06
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2023-10-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-06
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-06
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 2022-08-11
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-05
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-08-05
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-08-05
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-05
Penalties and ownership
Fine · fine $845
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
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