Cycle 1
Health 2024-10-03 · Fire 2024-10-03
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Wray, CO
Hillcrest Care Center
4-star overall rating with 4-star inspections with $49,385 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
360 Canyon Ridge Dr, Wray, CO
(970) 332-4856
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
45
Certified beds
Average residents
40
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-01-01
CMS approved date
Coverage
Medicare + Medicaid
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
0.76
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,545
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0030
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
5.16
Performance 6.29% · Measure score 5.16 · Achievement 5.16 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.06
Performance 51.16% · Measure score 3.06 · Achievement 3.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.51
Baseline 5.17 hours · Performance 4.93 hours · Measure score 6.51 · Achievement 6.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 6.4% |
| Discharge to community | 44.66% |
50.57%
5.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 42.86% · Lower 95% interval 33.87% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| 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 | 61.9% |
53.69%
8.2 pts better
|
Numerator 13 · Denominator 21 |
| Discharge mobility score | 61.9% |
50.94%
11 pts better
|
Numerator 13 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 1 · Denominator 30 · Adjusted rate 5.19% |
| Healthcare-associated infections requiring hospitalization | 6.29% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 2.98% |
| Staff COVID-19 vaccination coverage | 10.34% |
8.2%
2.1 pts better
|
Numerator 9 · Denominator 87 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 14 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · 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 | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
93.5%
1.7 pts better
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 88.9% · Q3 91.7% · Q4 100.0% · 4Q avg 95.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 61.5% |
94.7%
33.2 pts worse
|
95.5%
34 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 61.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.4%
2.8 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.6% · Q3 5.6% · Q4 10.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
7.4%
6.7 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.0%
0.1 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 11.8% · Q3 2.9% · Q4 2.8% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
11.2%
4 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 5.7% · Q3 5.7% · Q4 7.9% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
20.6%
10.3 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.1% · Q3 10.0% · Q4 9.4% · 4Q avg 10.3% · 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 | 14.5% |
15.2%
0.7 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 16.9% · Q3 0.0% · Q4 11.7% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
14.6%
0.8 pts worse
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 15.2% · Q3 2.9% · Q4 13.2% · 4Q avg 15.4% · 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 | 0.0% |
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 | 13.1% |
22.4%
9.3 pts better
|
19.8%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.6% · Q3 17.1% · Q4 12.8% · 4Q avg 13.1% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
3.7%
6 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 20.2% · Q3 13.9% · Q4 4.3% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.8% |
76.4%
17.6 pts worse
|
81.7%
22.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.9% · Q2 73.9% · Q3 52.2% · 4Q avg 58.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
12.8%
1.7 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 12.1% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 33.3% |
75.6%
42.3 pts worse
|
79.7%
46.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 33.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.4% |
20.3%
7.9 pts better
|
23.9%
11.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 9.1% · Expected 17.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (12 deficiencies)
Cycle 3
Health 2021-12-16 · Fire 2021-12-16
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-10-03
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-11-19
F · Potential for more than minimal harm
2024-10-03
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 2024-10-23
F · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-22
F · Potential for more than minimal harm
2024-10-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-03-30
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-30
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-04-27
F · Potential for more than minimal harm
2021-12-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-12-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-29
D · Potential for more than minimal harm
2021-12-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-12-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-29
D · Potential for more than minimal harm
2021-12-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-27
D · Potential for more than minimal harm
2021-12-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-02
D · Potential for more than minimal harm
2024-10-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-02
D · Potential for more than minimal harm
2024-10-03
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-03
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 2024-11-02
E · Potential for more than minimal harm
2024-07-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-28
G · Actual harm
2023-03-30
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 2023-04-27
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 2023-04-27
E · Potential for more than minimal harm
2023-03-30
F585 · Resident Rights Deficiencies
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 2023-04-27
E · Potential for more than minimal harm
2023-03-30
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-04-27
E · Potential for more than minimal harm
2023-03-30
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-30
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-04-27
G · Actual harm
2021-12-16
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 2022-01-24
E · Potential for more than minimal harm
2021-12-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-01-20
E · Potential for more than minimal harm
2021-12-16
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 2022-01-06
E · Potential for more than minimal harm
2021-12-16
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 2022-01-24
D · Potential for more than minimal harm
2021-12-16
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2022-01-05
D · Potential for more than minimal harm
2021-12-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-01-12
Penalties and ownership
What sits behind the stars
$4,587
2023-09-05
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-21
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-14
Fine
Fine · fine $4,587
Fine
$11,645
2023-07-24
Fine
Fine · fine $11,645
Fine
$23,979
2023-03-30
Fine
Fine · fine $23,979
Fine
Ownership
Wray Community Long Term Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Wray Community Long Term Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Bryant, Kimberly
Operational/Managerial Control · Individual
Hendrix, James
Corporate Director · Individual
Kriley, Thomas
Corporate Director · Individual
Soehner, Craig
Corporate Director · Individual
Wingfield, Jeffrey
Corporate Director · Individual
Wray Community Long Term Care, Inc.
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Cheyenne County Village Inc
St Francis, KS
2-star overall rating with 2-star inspections with $13,287 in total fines with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Sarah Ann Hester Memorial Home
Benkelman, NE
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Regent Park Nursing And Rehabilitation
Holyoke, CO
5-star overall rating with 5-star inspections with $8,469 in total fines with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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