17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lakewood, CO
3-star overall rating with 2-star inspections with $1,576 in total fines with 17 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
1655 Yarrow St, Lakewood, CO
(303) 238-3838
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
125
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vivage Senior Living
Operator or chain grouping
Approved since
1991-12-01
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
RN hours / resident day
0.68
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.54
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
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
4,672
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
5.79
Baseline 57.14% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 4.81
Adjusted total nurse staffing
2.01
Baseline 3.78 hours · Performance 3.65 hours · Measure score 2.01 · Achievement 2.01 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 11 · 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 6 · 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 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · 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 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 12.75% |
8.2%
4.6 pts better
|
Numerator 19 · Denominator 149 |
| Staff flu vaccination coverage | 96.64% |
42%
54.6 pts better
|
Numerator 144 · Denominator 149 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · 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 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
93.5%
4.3 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 97.2% · Q3 96.1% · Q4 99.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
94.7%
About the same
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.4%
1.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.8% · Q3 1.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
7.4%
6.4 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
5.0%
4.5 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 15.8% · Q3 7.5% · Q4 2.1% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
11.2%
2.1 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.8% · Q3 9.5% · Q4 9.5% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.5% |
20.6%
12.9 pts worse
|
16.7%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 35.9% · Q3 34.4% · Q4 29.7% · 4Q avg 33.5% · 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 | 2.8% |
15.2%
12.4 pts better
|
16.3%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 3.3% · Q4 3.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
14.6%
10.4 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.2% · Q3 3.4% · Q4 1.2% · 4Q avg 4.2% · 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 1.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
22.4%
2.8 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 16.4% · Q3 17.1% · Q4 23.3% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
3.7%
1.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.3% · Q3 1.1% · Q4 1.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.4% |
76.4%
7 pts worse
|
81.7%
12.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.0% · Q2 68.4% · Q3 66.7% · Q4 73.9% · 4Q avg 69.4% |
| 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 · 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 | 57.6% |
75.6%
18 pts worse
|
79.7%
22.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.6% |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-11-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-20
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-10-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-20
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-11-29
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-31
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 2024-10-17
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-11-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-20
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-17
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-01
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 2023-06-06
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-05
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-20
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-09
Fire Safety
Have an externally vented heating system.
Corrected 2023-06-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-28
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-03-28
Inspection history
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-10-25
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 2024-10-25
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-25
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 2024-10-25
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-25
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-10-25
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-25
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-25
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-25
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 2024-10-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-25
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 2024-10-25
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 2024-10-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-11
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 2023-05-11
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-11
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-11
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-05-11
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-05-11
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-02-15
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 2022-02-15
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-02-15
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 2022-02-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-02-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-02-15
Penalties and ownership
Fine · fine $1,576
Fine
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Nearby options
Lakewood, CO
2-star overall rating with 2-star inspections with abuse icon flag with $34,580 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Lakewood, CO
5-star overall rating with 5-star inspections with 5 recent health deficiencies
Lakewood, CO
1-star overall rating with 1-star inspections with $31,663 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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