Holly, CO

Holly Care Center

5-star overall rating with 4-star inspections with 3 recent health deficiencies

320 N 8th St, Holly, CO

(719) 537-6555

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

45

Certified beds

Average residents

28

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Vivage Senior Living

Operator or chain grouping

Approved since

1996-06-01

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

Hours and turnover

RN hours / resident day

0.82

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.60

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

3.16

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.82

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.52

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

1.05

CMS adjusted RN staffing hours

Adjusted total hours

4.04

CMS adjusted total nurse staffing hours

Case-mix index

1.07

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

38%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,079

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

Performance score

46.14

Composite VBP score used to determine payment impact.

Payment multiplier

0.9995

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

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

4.37

Baseline 46.15% · Performance 45.83% · Measure score 4.37 · Achievement 4.37 · Improvement 0

Adjusted total nurse staffing

4.86

Performance 4.46 hours · Measure score 4.86 · Achievement 4.86 · This facility did not have sufficient data to calculate a baseline period measure result.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 10 · 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 7 · 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 9 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 9 · 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 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	2.04%	8.2% 6.2 pts worse	Numerator 1 · Denominator 49
Staff flu vaccination coverage	100%	42% 58 pts better	Numerator 54 · Denominator 54
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 6 · 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	0.2	1.3 1.1 pts better	1.9 1.7 pts better	Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.6	1.7 0.9 pts worse	1.8 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.0 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.1%	93.5% 3.6 pts better	93.4% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.3% · Q3 96.0% · Q4 96.2% · 4Q avg 97.1%
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	0.0%	3.4% 3.4 pts better	3.3% 3.3 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 who have depressive symptoms	1.1%	7.4% 6.3 pts better	11.4% 10.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1%
Percentage of long-stay residents who lose too much weight	3.3%	5.0% 1.7 pts better	5.4% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 0.0% · Q4 4.3% · 4Q avg 3.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.7%	11.2% 1.5 pts better	19.6% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 8.3% · Q3 13.0% · Q4 13.0% · 4Q avg 9.7%
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 · 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	9.0%	15.2% 6.2 pts better	16.3% 7.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.3%	14.6% 4.3 pts better	14.9% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 9.1% · Q3 8.7% · Q4 4.8% · 4Q avg 10.3% · 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	9.5%	22.4% 12.9 pts better	19.8% 10.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 11.4% · Q3 14.4% · Q4 7.6% · 4Q avg 9.5%
Percentage of long-stay residents with pressure ulcers	7.7%	3.7% 4 pts worse	5.1% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 8.4% · Q3 9.0% · Q4 3.7% · 4Q avg 7.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	71.2%	76.4% 5.2 pts worse	81.7% 10.5 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 71.2%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-28 · Fire 2024-08-28

3 health deficiencies

Top issue: Infection Control (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-03-30 · Fire 2023-03-30

5 health deficiencies

Top issue: Environmental (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2021-12-16 · Fire 2021-12-16

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · 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 2023-06-13

D · Potential for more than minimal harm 2023-03-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-04-26

D · Potential for more than minimal harm 2023-03-30

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-04-25

D · Potential for more than minimal harm 2021-12-16

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-01-26

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 2022-01-26

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-08-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-28

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-28

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2024-09-04

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 2023-04-13

F · Potential for more than minimal harm 2023-03-30

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-04-13

E · Potential for more than minimal harm 2023-03-30

F584 · Resident Rights Deficiencies

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 2023-04-13

D · Potential for more than minimal 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 2023-04-13

D · Potential for more than minimal harm 2023-03-30

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2023-04-21

D · Potential for more than minimal harm 2021-12-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2021-12-20

D · 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 2021-12-20

Penalties and ownership