Greeley, CO

Grace Pointe Cont Care Sr Campus, Skilled Nursing

5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1919 68th Ave, Greeley, CO

(970) 304-1919

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

53

Certified beds

Average residents

47

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2009-11-30

CMS approved date

Coverage

Medicare

Participation flags

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

1.14

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.61

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.75

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.51

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.76

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

3.89

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.84

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.22

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

1.27

CMS adjusted RN staffing hours

Adjusted total hours

5.01

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

14%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,010

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

52.32

Composite VBP score used to determine payment impact.

Payment multiplier

1.0068

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.75

Baseline 18.29% · Performance 18.77% · Measure score 5.75 · Achievement 5.75 · Improvement 0

Healthcare-associated infections

3.88

Baseline 4.52% · Performance 6.67% · Measure score 3.88 · Achievement 3.88 · Improvement 0

Total nurse turnover

6.90

Baseline 46.00% · Performance 35.48% · Measure score 6.90 · Achievement 6.90 · Improvement 4.47

Adjusted total nurse staffing

4.40

Baseline 3.87 hours · Performance 4.33 hours · Measure score 4.40 · Achievement 4.40 · Improvement 1.89

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.33%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 181 · Observed rate 8.29% · Lower 95% interval 7.3%
Discharge to community	46.55%	50.57% 4 pts worse	No Different than the National Rate · Eligible stays 192 · Observed rate 44.27% · Lower 95% interval 39.19%
Medicare spending per beneficiary	0.91	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 91 · Denominator 91
Falls with major injury	1.1%	0.77% 0.3 pts worse	Numerator 1 · Denominator 91
Discharge self-care score	70.77%	53.69% 17.1 pts better	Numerator 46 · Denominator 65
Discharge mobility score	50.77%	50.94% 0.2 pts worse	Numerator 33 · Denominator 65
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 91 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.67%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 99 · Observed rate 5.05% · Lower 95% interval 3.94%
Staff COVID-19 vaccination coverage	2.22%	8.2% 6 pts worse	Numerator 3 · Denominator 135
Staff flu vaccination coverage	92.52%	42% 50.5 pts better	Numerator 198 · Denominator 214
Discharge function score	56.92%	56.45% 0.5 pts better	Numerator 37 · Denominator 65
Transfer of health information to provider	93.33%	95.95% 2.6 pts worse	Numerator 28 · Denominator 30
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 54 · Denominator 54
Resident COVID-19 vaccinations up to date	21.74%	25.2% 3.5 pts worse	Numerator 10 · Denominator 46

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.2	1.3 1.1 pts better	1.9 1.7 pts better	Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.9 · 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 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.5%	93.5% 5 pts better	93.4% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.8% · Q4 96.7% · 4Q avg 98.5%
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	1.5%	3.4% 1.9 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.6%	7.4% 5.8 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.7% · Q4 0.0% · 4Q avg 1.6%
Percentage of long-stay residents who lose too much weight	1.9%	5.0% 3.1 pts better	5.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.5%	11.2% 4.7 pts better	19.6% 13.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.8% · Q3 7.7% · Q4 7.4% · 4Q avg 6.5%
Percentage of long-stay residents who received an antipsychotic medication	11.8%	20.6% 8.8 pts better	16.7% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 12.5% · Q3 13.0% · Q4 4.3% · 4Q avg 11.8% · 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	14.6%	15.2% 0.6 pts better	16.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.6%	14.6% 4 pts worse	14.9% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 21.7% · Q3 8.0% · Q4 11.1% · 4Q avg 18.6% · 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	1.6%	1.5% 0.1 pts worse	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 3.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.5%	22.4% 3.1 pts worse	19.8% 5.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 41.1% · Q3 17.8% · Q4 23.2% · 4Q avg 25.5%
Percentage of long-stay residents with pressure ulcers	1.6%	3.7% 2.1 pts better	5.1% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.6% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	78.2%	76.4% 1.8 pts better	81.7% 3.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 75.7% · Q3 77.9% · Q4 76.4% · 4Q avg 78.2%
Percentage of short-stay residents who had an outpatient emergency department visit	18.8%	12.8% 6 pts worse	12.0% 6.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 16.7% · Expected 9.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.5% 1.2 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	73.9%	75.6% 1.7 pts worse	79.7% 5.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.6%	20.3% 1.7 pts better	23.9% 5.3 pts better	Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 16.7% · Expected 21.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-11-16 · Fire 2023-11-16

3 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2022-08-11 · Fire 2022-08-11

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-05-26 · Fire 2021-05-26

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-11-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-18

F · Potential for more than minimal harm 2023-11-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-02-27

D · Potential for more than minimal harm 2023-11-16

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-02-27

F · Potential for more than minimal harm 2022-08-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-09-30

F · Potential for more than minimal harm 2022-08-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-09-03

F · Potential for more than minimal harm 2022-08-11

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-01-25

F · Potential for more than minimal harm 2022-08-11

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-09-02

F · Potential for more than minimal harm 2021-05-26

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2021-07-12

F · Potential for more than minimal harm 2021-05-26

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-06-24

Inspection history

Recent health citations

G · Actual harm 2025-10-22

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 2025-11-13

D · Potential for more than minimal harm 2023-11-16

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 2023-12-15

D · Potential for more than minimal harm 2023-11-16

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 2023-12-15

F · Potential for more than minimal harm 2022-08-11

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 2022-09-01

D · Potential for more than minimal harm 2022-08-11

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-09-01

D · Potential for more than minimal harm 2022-08-11

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-09-01

D · Potential for more than minimal harm 2022-08-11

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-09-01

D · Potential for more than minimal harm 2022-08-11

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2022-09-01

D · Potential for more than minimal harm 2022-08-11

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 2022-09-01

E · Potential for more than minimal harm 2021-05-26

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 2021-06-24