Cycle 1
Health 2024-01-09 · Fire 2024-01-09
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Denver, CO
Denver North Care Center
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2201 N Downing St, Denver, CO
(303) 861-4825
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vivage Senior Living
Operator or chain grouping
Approved since
1994-04-15
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
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.64
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.98
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.58
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.35
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
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,398
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9976
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
5.80
Baseline 75.00% · Performance 43.40% · Measure score 5.80 · Achievement 4.96 · Improvement 5.80
Adjusted total nurse staffing
3.10
Baseline 4.07 hours · Performance 3.96 hours · Measure score 3.10 · Achievement 3.10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 1 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 54.72% |
42%
12.7 pts better
|
Numerator 58 · Denominator 106 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
93.5%
3.1 pts worse
|
93.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 94.5% · Q3 90.8% · Q4 84.8% · 4Q avg 90.4% |
| 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 | 1.3% |
3.4%
2.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.6% |
7.4%
4.2 pts worse
|
11.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 13.1% · Q3 10.4% · Q4 12.1% · 4Q avg 11.6% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.0%
0.7 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 3.0% · Q3 2.8% · Q4 5.4% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
11.2%
1.6 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 9.0% · Q3 12.5% · Q4 9.5% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.9% |
20.6%
20.3 pts worse
|
16.7%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.4% · Q2 48.5% · Q3 38.2% · Q4 37.8% · 4Q avg 40.9% · 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 | 7.8% |
15.2%
7.4 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.7% · Q3 4.5% · Q4 16.4% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
14.6%
8.3 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.6% · Q3 10.3% · Q4 9.9% · 4Q avg 6.3% · 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 | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.8% |
22.4%
10.6 pts better
|
19.8%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 7.5% · Q3 13.0% · Q4 15.9% · 4Q avg 11.8% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
3.7%
1.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.5% · Q3 0.0% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.7% |
76.4%
54.7 pts worse
|
81.7%
60 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 21.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-15 · Fire 2022-09-15
12 health deficiencies
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2021-06-23 · Fire 2021-06-23
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-14
F · Potential for more than minimal harm
2024-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-14
F · Potential for more than minimal harm
2024-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-08
E · Potential for more than minimal harm
2024-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-31
E · Potential for more than minimal harm
2024-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-05
F · Potential for more than minimal harm
2022-09-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-11
F · Potential for more than minimal harm
2022-09-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-11
F · Potential for more than minimal harm
2021-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-07-21
D · Potential for more than minimal harm
2021-06-23
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-07-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-11
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 2025-03-07
D · Potential for more than minimal harm
2025-02-11
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-11
F · Potential for more than minimal harm
2024-01-09
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 2024-02-08
E · Potential for more than minimal harm
2024-01-09
F584 · Resident Rights Deficiencies
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 2024-02-08
E · Potential for more than minimal harm
2024-01-09
F758 · Pharmacy Service Deficiencies
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 2024-02-15
E · Potential for more than minimal harm
2024-01-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-09
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-09
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 2024-02-15
D · Potential for more than minimal harm
2024-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-09
F742 · Quality of Life and Care Deficiencies
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 2024-02-15
F · Potential for more than minimal harm
2022-09-15
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-15
F758 · Pharmacy Service Deficiencies
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 2022-10-14
E · Potential for more than minimal harm
2022-09-15
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 2022-10-07
E · Potential for more than minimal harm
2022-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-15
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-15
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-15
F690 · Quality of Life and Care Deficiencies
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 2022-10-14
D · Potential for more than minimal harm
2022-09-15
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-10-14
G · Actual harm
2021-06-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-07-09
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Health Center At Franklin Park
Denver, CO
4-star overall rating with 3-star inspections with $10,082 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Uptown Care Center
Denver, CO
4-star overall rating with 2-star inspections with abuse icon flag with $8,278 in total fines with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Briarwood Health Care Center
Denver, CO
4-star overall rating with 3-star inspections with $47,867 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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