Cycle 1
Health 2024-05-07 · Fire 2024-05-07
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Loveland, CO
Good Samaritan Society -- Loveland Village
4-star overall rating with 4-star inspections with $35,489 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2101 S Garfield Ave, Loveland, CO
(970) 669-3100
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
100
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1976-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 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
1.01
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,251
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.45
Baseline 17.82% · Performance 19.37% · Measure score 4.45 · Achievement 4.45 · Improvement 0
Healthcare-associated infections
2.24
Baseline 6.97% · Performance 7.17% · Measure score 2.24 · Achievement 2.24 · Improvement 0
Total nurse turnover
6.39
Baseline 67.39% · Performance 38.09% · Measure score 6.39 · Achievement 6.26 · Improvement 6.39
Adjusted total nurse staffing
1.67
Baseline 3.50 hours · Performance 3.55 hours · Measure score 1.67 · Achievement 1.67 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.71% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 2.33% · Lower 95% interval 5.59% |
| Discharge to community | 45.65% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 43.48% · Lower 95% interval 38.11% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 45 · Denominator 45 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 45 |
| Discharge self-care score | 65.63% |
53.69%
11.9 pts better
|
Numerator 21 · Denominator 32 |
| Discharge mobility score | 65.63% |
50.94%
14.7 pts better
|
Numerator 21 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 45 · Adjusted rate 2.23% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 48 · Observed rate 6.25% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 5.47% |
8.2%
2.7 pts worse
|
Numerator 11 · Denominator 201 |
| Staff flu vaccination coverage | 95.28% |
42%
53.3 pts better
|
Numerator 343 · Denominator 360 |
| Discharge function score | 68.75% |
56.45%
12.3 pts better
|
Numerator 22 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 42.31% |
25.2%
17.1 pts better
|
Numerator 11 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
93.5%
5.9 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 98.9% · 4Q avg 99.4% |
| 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 | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.7% · Q3 2.3% · Q4 1.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
7.4%
5.1 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 5.3% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.0%
0.2 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.0% · Q3 5.5% · Q4 6.8% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
11.2%
0.1 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 11.6% · Q3 10.7% · Q4 10.8% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
20.6%
4.8 pts better
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 14.3% · Q3 15.9% · Q4 18.1% · 4Q avg 15.8% · 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 | 28.0% |
15.2%
12.8 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 35.2% · Q4 16.2% · 4Q avg 28.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
14.6%
3.9 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 20.9% · Q3 15.5% · Q4 8.5% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.8%
0.1 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.3% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.5%
1.7 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.1% · Q3 4.7% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
22.4%
2.9 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 34.0% · Q3 19.3% · Q4 17.8% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
3.7%
4.5 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.9% · Q3 8.5% · Q4 7.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.9% |
76.4%
10.5 pts better
|
81.7%
5.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 80.5% · Q3 88.0% · Q4 90.4% · 4Q avg 86.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
12.8%
7 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 5.1% · Expected 9.9% · 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 | 77.9% |
75.6%
2.3 pts better
|
79.7%
1.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
20.3%
3.1 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 20.5% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-07 · Fire 2023-02-07
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-11-18 · Fire 2021-11-18
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-07
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-07
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 2024-06-04
F · Potential for more than minimal harm
2023-02-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-02-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-08
F · Potential for more than minimal harm
2021-11-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-07
F · Potential for more than minimal harm
2021-11-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-17
F · Potential for more than minimal harm
2021-11-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-07
F · Potential for more than minimal harm
2021-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-11-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-11
Inspection history
Recent health citations
G · Actual harm
2025-02-26
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 2025-03-10
J · Immediate jeopardy
2024-10-22
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 2024-08-02
G · Actual harm
2024-05-07
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 2024-05-04
D · Potential for more than minimal harm
2024-05-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-01
G · Actual harm
2023-02-07
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 2023-03-04
E · Potential for more than minimal harm
2023-02-07
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 2023-03-04
G · Actual harm
2021-11-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-12-17
E · Potential for more than minimal harm
2021-11-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-12-17
E · Potential for more than minimal harm
2021-11-18
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 2021-12-17
D · Potential for more than minimal harm
2021-11-18
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 2021-12-17
D · Potential for more than minimal harm
2021-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-18
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 2021-12-17
D · Potential for more than minimal harm
2021-11-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-15
Penalties and ownership
What sits behind the stars
$13,059
2025-02-26
Fine
Fine · fine $13,059
Fine
$15,642
2024-10-22
Fine
Fine · fine $15,642
Fine
$6,788
2024-05-07
Fine
Fine · fine $6,788
Fine
Ownership
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect Ownership Interest · Organization
Brown, George
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Freitas, Diego
Operational/Managerial Control · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lehto, Tammi
Operational/Managerial Control · Individual
Lundeen, Mark
Corporate Director · Individual
Mccausland, Maureen
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Operational/Managerial Control · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Sandgren, Deeandra
Operational/Managerial Control · Individual
Sanford
5% Or Greater Direct Ownership Interest · Organization
Schema, Nathan
Corporate Officer · Individual
Schieffer, Kevin
Corporate Director · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
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Green House Homes At Mirasol, The
Loveland, CO
5-star overall rating with 4-star inspections with $7,544 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Riverbend Health And Rehabilitation Center
Loveland, CO
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
North Shore Health & Rehab Facility
Loveland, CO
4-star overall rating with 4-star inspections with $4,233 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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