Cycle 1
Health 2024-06-06 · Fire 2024-06-06
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Greeley, CO
Fairacres Manor, Inc.
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
1700 18th Ave, Greeley, CO
(970) 353-3370
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
Facility snapshot
Beds
116
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Frontline Management
Operator or chain grouping
Approved since
1985-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.85
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,629
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0101
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.83
Baseline 18.38% · Performance 18.73% · Measure score 5.83 · Achievement 5.83 · Improvement 0
Healthcare-associated infections
6.84
Baseline 5.51% · Performance 5.79% · Measure score 6.84 · Achievement 6.84 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.88
Baseline 4.03 hours · Performance 4.18 hours · Measure score 3.88 · Achievement 3.88 · Improvement 0.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.3% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 4.62% · Lower 95% interval 6.48% |
| Discharge to community | 54.54% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 50% · Lower 95% interval 40.94% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 34 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 16 · Denominator 30 |
| Discharge mobility score | 43.33% |
50.94%
7.6 pts worse
|
Numerator 13 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 0% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 2.67% |
8.2%
5.5 pts worse
|
Numerator 5 · Denominator 187 |
| Staff flu vaccination coverage | 83.71% |
42%
41.7 pts better
|
Numerator 185 · Denominator 221 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 15 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| 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 1.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
93.5%
1 pts worse
|
93.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 90.5% · Q3 94.7% · Q4 91.0% · 4Q avg 92.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
94.7%
2.3 pts worse
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.4%
0.3 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.1% · Q3 2.1% · Q4 4.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
7.4%
3.6 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 2.4% · Q3 2.3% · Q4 3.3% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.0%
0.2 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.8% · Q3 4.9% · Q4 7.1% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.3% |
11.2%
3.9 pts better
|
19.6%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 6.2% · Q3 6.1% · Q4 8.0% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
20.6%
3.4 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 27.1% · Q3 23.9% · Q4 19.7% · 4Q avg 24.0% · 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 | 35.6% |
15.2%
20.4 pts worse
|
16.3%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 36.5% · Q3 35.3% · Q4 38.6% · 4Q avg 35.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.9% |
14.6%
19.3 pts worse
|
14.9%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 29.5% · Q3 41.0% · Q4 39.8% · 4Q avg 33.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.8%
0.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
1.5%
3.2 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.2% · Q3 7.4% · Q4 3.1% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.4% |
22.4%
10 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 26.9% · Q3 28.5% · Q4 30.3% · 4Q avg 32.4% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
3.7%
2.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.2% · Q3 0.0% · Q4 1.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
76.4%
0.8 pts better
|
81.7%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 77.8% · Q3 80.0% · Q4 69.5% · 4Q avg 77.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
12.8%
0.3 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.0% · Expected 10.7% · 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 | 84.2% |
75.6%
8.6 pts better
|
79.7%
4.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.1% |
20.3%
7.2 pts better
|
23.9%
10.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 12.0% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-13 · Fire 2020-02-13
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-02-21 · Fire 2019-02-21
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-06-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-06-06
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 2024-09-03
F · Potential for more than minimal harm
2024-06-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-06-06
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-06-06
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-06-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-06-06
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-06-06
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-06-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-06-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-06-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-03
D · Potential for more than minimal harm
2020-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-04-30
D · Potential for more than minimal harm
2020-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-30
D · Potential for more than minimal harm
2020-02-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-03-12
F · Potential for more than minimal harm
2019-02-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-04-15
F · Potential for more than minimal harm
2019-02-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-06
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 2024-06-23
E · Potential for more than minimal harm
2024-06-06
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-06-23
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-23
G · Actual harm
2020-02-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-13
F · Potential for more than minimal harm
2020-02-13
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 2020-03-13
F · Potential for more than minimal harm
2020-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-13
E · Potential for more than minimal harm
2020-02-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-13
E · Potential for more than minimal harm
2020-02-13
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 2020-03-13
D · Potential for more than minimal harm
2020-02-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-03-13
D · Potential for more than minimal harm
2020-02-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2020-03-13
D · Potential for more than minimal harm
2020-02-13
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 2020-03-13
D · Potential for more than minimal harm
2019-02-21
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-03-28
D · Potential for more than minimal harm
2019-02-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-03-21
D · Potential for more than minimal harm
2019-02-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-03-21
D · Potential for more than minimal harm
2019-02-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2019-03-21
D · Potential for more than minimal harm
2019-02-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-03-28
D · Potential for more than minimal harm
2019-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-03-21
Penalties and ownership
What sits behind the stars
Ownership
Nelson, Jill
5% Or Greater Direct Ownership Interest · Individual
Bidell, Thomas
Corporate Director · Individual
Gonzales, Benjamin
W-2 Managing Employee · Individual
Koretke, Mary
W-2 Managing Employee · Individual
Pinon Management, LLC
Operational/Managerial Control · Organization
Qp Health Care Services LLC
Operational/Managerial Control · Organization
Shepherd, Kristine
W-2 Managing Employee · Individual
Trujillo, Marla
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Broadview Health And Rehabilitation Center
Greeley, CO
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Westlake Health And Rehabilitation Center
Greeley, CO
3-star overall rating with 3-star inspections with $14,069 in total fines with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Center At Centerplace, LLC, The
Greeley, CO
2-star overall rating with 2-star inspections with $39,384 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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