Cycle 1
Health 2024-10-17 · Fire 2024-10-17
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Glenwood Springs, CO
Glenwood Springs Healthcare
2-star overall rating with 3-star inspections with $5,293 in total fines with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
2305 Blake Ave, Glenwood Springs, CO
(970) 945-5476
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Madison Creek Partners
Operator or chain grouping
Approved since
1988-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 3 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,472
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
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
0.97
Baseline 6.58% · Performance 7.55% · Measure score 0.97 · Achievement 0.97 · 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
0
Baseline 2.81 hours · Performance 2.46 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.08% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 11.27% · Lower 95% interval 7.7% |
| Discharge to community | 38.65% |
50.57%
11.9 pts worse
|
Worse than the National Rate · Eligible stays 66 · Observed rate 31.82% · Lower 95% interval 27.01% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 9 · Denominator 21 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 12 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.55% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 25 |
| Staff flu vaccination coverage | 60% |
42%
18 pts better
|
Numerator 24 · Denominator 40 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 11 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.4% |
3.4%
4 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 12.1% · Q3 9.4% · Q4 2.9% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
7.4%
1.8 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 16.1% · Q4 7.1% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 19.4% |
11.2%
8.2 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 30.3% · Q3 21.9% · Q4 14.7% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.0% |
20.6%
9.4 pts worse
|
16.7%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 28.0% · Q3 29.2% · Q4 36.0% · 4Q avg 30.0% · 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 | 8.2% |
15.2%
7 pts better
|
16.3%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
14.6%
2.7 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 6.2% · Q3 10.3% · Q4 16.1% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.8%
0.2 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 13.0% |
22.4%
9.4 pts better
|
19.8%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 17.7% · Q3 15.9% · Q4 9.2% · 4Q avg 13.0% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
3.7%
0.9 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.6% · Q3 4.1% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
76.4%
16.7 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 91.3% · Q3 94.4% · Q4 93.3% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
12.8%
0.1 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.0% · Expected 10.5% · 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 · Q2 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 | 82.6% |
75.6%
7 pts better
|
79.7%
2.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
20.3%
4.7 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 24.0% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-01-11 · Fire 2022-01-11
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-12
F · Potential for more than minimal harm
2024-10-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-12
F · Potential for more than minimal harm
2024-10-17
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-10-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-12
F · Potential for more than minimal harm
2024-10-17
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 2024-11-29
E · Potential for more than minimal harm
2024-10-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-12
E · Potential for more than minimal harm
2024-10-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-17
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 2024-11-29
D · Potential for more than minimal harm
2024-10-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-10-17
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-10-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-10-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-10-17
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-12-20
E · Potential for more than minimal harm
2023-03-30
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 2023-04-24
E · Potential for more than minimal harm
2023-03-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-03-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-27
E · Potential for more than minimal harm
2022-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-02-17
E · Potential for more than minimal harm
2022-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-01-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-15
D · Potential for more than minimal harm
2022-01-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-17
D · Potential for more than minimal harm
2022-01-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-14
D · Potential for more than minimal harm
2022-01-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-17
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-17
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 2024-11-15
E · Potential for more than minimal harm
2024-10-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-17
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 2024-11-10
E · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-15
G · Actual harm
2024-07-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-24
F · Potential for more than minimal harm
2023-03-30
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
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 2023-04-28
F · Potential for more than minimal harm
2023-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-28
G · Actual harm
2022-01-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-01-25
F · Potential for more than minimal harm
2022-01-11
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 2022-01-25
E · Potential for more than minimal harm
2022-01-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-01-25
E · Potential for more than minimal harm
2022-01-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-01-25
D · Potential for more than minimal harm
2022-01-11
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-01-25
D · Potential for more than minimal harm
2022-01-11
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 2022-01-25
Penalties and ownership
What sits behind the stars
$5,293
2023-09-05
Fine
Fine · fine $5,293
Fine
Ownership
Christensen, Covey
5% Or Greater Indirect Ownership Interest · Individual
Madison Creek Partners LLC
5% Or Greater Direct Ownership Interest · Organization
Christensen, Covey
Operational/Managerial Control · Individual
Christensen, Covey
Corporate Officer · Individual
Christensen, Covey
W-2 Managing Employee · Individual
Hopkins, Amber
Corporate Director · Individual
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