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
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 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
0.84
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.86
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.52
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
2.97
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
2,362
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 29.17% · Performance 17.78% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0
Baseline 3.49 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 6.61% |
| Discharge to community | 52.86% |
50.57%
2.3 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 46.43% · Lower 95% interval 37.89% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 29 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.48% |
8.2%
5.3 pts better
|
Numerator 12 · Denominator 89 |
| Staff flu vaccination coverage | 96.94% |
42%
54.9 pts better
|
Numerator 95 · Denominator 98 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
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 · Adjusted 1.4 · Observed 1.6 · Expected 2.2 · Used in QM five-star |
| 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 · Adjusted 1.3 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| 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 · Q1 93.7% · Q2 86.3% · Q3 84.6% · Q4 87.5% · 4Q avg 88.1% |
| 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 · 4Q avg 88.4% |
| 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 · Q1 1.3% · Q2 2.7% · Q3 3.8% · Q4 5.0% · 4Q avg 3.2% · Used in QM five-star |
| 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 · Q1 5.6% · Q2 2.9% · Q3 0.0% · Q4 1.4% · 4Q avg 2.5% |
| 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 · Q1 2.8% · Q2 4.3% · Q3 1.4% · Q4 5.6% · 4Q avg 3.5% |
| 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 · Q1 4.0% · Q2 4.3% · Q3 8.1% · Q4 8.3% · 4Q avg 6.2% |
| 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 · Q1 22.4% · Q2 20.8% · Q3 21.6% · Q4 22.7% · 4Q avg 21.9% · 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 | 2.9% |
15.2%
12.3 pts better
|
16.3%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 0.0% · Q4 5.1% · 4Q avg 2.9% · Used in QM five-star |
| 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 · Q1 7.2% · Q2 1.7% · Q3 0.0% · Q4 3.1% · 4Q avg 3.1% · 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 · 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 with a urinary tract infection | 0.3% |
1.5%
1.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| 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 · Q1 6.7% · Q2 5.9% · Q3 5.2% · Q4 9.9% · 4Q avg 7.0% |
| 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 · Q1 1.5% · Q2 3.3% · Q3 6.3% · Q4 4.5% · 4Q avg 3.9% · Used in QM five-star |
| 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 · Q1 37.3% · Q2 31.0% · Q3 35.9% · Q4 63.0% · 4Q avg 41.0% |
| 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 · Q1 2.9% · Q2 0.0% · 4Q avg 2.1% · Used in QM five-star |
| 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 · 4Q avg 37.9% |
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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5-star overall rating with 3-star inspections with $17,160 in total fines with 3 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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2-star overall rating with 1-star inspections with $66,307 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Denver, CO
3-star overall rating with 2-star inspections with $4,622 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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