Cycle 1
Health 2025-05-15 · Fire 2025-05-15
4 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Evergreen, CO
Life Care Center Of Evergreen
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2987 Bergen Peak Dr, Evergreen, CO
(303) 674-4500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1990-04-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 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
1.18
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,044
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9945
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.86
Baseline 17.76% · Performance 20.11% · Measure score 2.86 · Achievement 2.86 · Improvement 0
Healthcare-associated infections
4.17
Baseline 6.29% · Performance 6.59% · Measure score 4.17 · Achievement 4.17 · Improvement 0
Total nurse turnover
7.61
Baseline 23.81% · Performance 32.56% · Measure score 7.61 · Achievement 7.61 · Improvement 0
Adjusted total nurse staffing
1.97
Baseline 3.60 hours · Performance 3.64 hours · Measure score 1.97 · Achievement 1.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 8.25% · Lower 95% interval 7.11% |
| Discharge to community | 59.13% |
50.57%
8.6 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 56.04% · Lower 95% interval 48.75% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.33% |
95.27%
2.1 pts better
|
Numerator 73 · Denominator 75 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 75 |
| Discharge self-care score | 78.72% |
53.69%
25 pts better
|
Numerator 37 · Denominator 47 |
| Discharge mobility score | 80.85% |
50.94%
29.9 pts better
|
Numerator 38 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 4.55% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 3.41% |
8.2%
4.8 pts worse
|
Numerator 3 · Denominator 88 |
| Staff flu vaccination coverage | 53.85% |
42%
11.9 pts better
|
Numerator 63 · Denominator 117 |
| Discharge function score | 80.85% |
56.45%
24.4 pts better
|
Numerator 38 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 30.23% |
25.2%
5 pts better
|
Numerator 13 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
93.5%
0.8 pts worse
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 93.0% · Q3 90.7% · Q4 100.0% · 4Q avg 92.7% |
| 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 | 4.8% |
3.4%
1.4 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.7% · Q3 4.7% · Q4 4.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
7.4%
2.3 pts worse
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.0% · Q3 16.7% · Q4 13.2% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.0%
0.4 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 7.7% · Q4 7.7% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
11.2%
0.5 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.1% · Q3 15.4% · Q4 12.5% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
20.6%
5.9 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 12.5% · Q3 14.3% · Q4 14.3% · 4Q avg 14.7% · 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 | 20.6% |
15.2%
5.4 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.9% |
14.6%
4.7 pts better
|
14.9%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 3.3% · Q3 3.0% · Q4 8.3% · 4Q avg 9.9% · 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 | 0.6% |
1.5%
0.9 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
22.4%
0.4 pts worse
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 25.1% · Q3 22.2% · Q4 22.7% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
3.7%
1.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 10.5% · Q3 4.6% · Q4 4.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
76.4%
18.2 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 94.9% · Q3 95.7% · Q4 99.1% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
12.8%
3.7 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 15.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.4% · Q3 0.0% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
75.6%
16.4 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
20.3%
1.3 pts worse
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 20.6% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-07-14 · Fire 2022-07-14
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-13
F · Potential for more than minimal harm
2023-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-06
F · Potential for more than minimal harm
2023-10-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-26
K222 · Egress Deficiencies
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 2023-12-06
D · Potential for more than minimal harm
2023-10-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-06
D · Potential for more than minimal harm
2022-07-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-10
D · Potential for more than minimal harm
2022-07-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-08-10
D · Potential for more than minimal harm
2022-07-14
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-08-10
D · Potential for more than minimal harm
2022-07-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-10
D · Potential for more than minimal harm
2022-07-14
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2022-08-09
D · Potential for more than minimal harm
2022-07-14
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 2022-08-12
D · Potential for more than minimal harm
2022-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-15
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 2025-05-30
D · Potential for more than minimal harm
2025-05-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-15
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-05-30
E · Potential for more than minimal harm
2023-10-26
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 2023-11-17
E · Potential for more than minimal harm
2023-10-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
E · Potential for more than minimal harm
2022-07-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-10
D · Potential for more than minimal harm
2022-07-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-10
D · Potential for more than minimal harm
2022-07-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-08-10
Penalties and ownership
What sits behind the stars
Ownership
Preston, Forrest
5% Or Greater Direct Ownership Interest · Individual
Carlson, Amber
W-2 Managing Employee · Individual
Cross, Cindy
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Thurmond, Joan
Corporate Officer · Individual
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