Cycle 1
Health 2024-05-09 · Fire 2024-05-09
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Littleton, CO
Orchard Park Health Care Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
6005 S Holly St, Littleton, CO
(303) 773-1000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
133
Certified beds
Average residents
125
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Clear Choice Healthcare
Operator or chain grouping
Approved since
1989-06-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 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
0.45
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
50%
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
3,694
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9960
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.47
Baseline 18.31% · Performance 17.97% · Measure score 7.47 · Achievement 7.47 · Improvement 2.16
Healthcare-associated infections
0
Baseline 6.37% · Performance 8.48% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.09
Baseline 62.79% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 4.75
Adjusted total nurse staffing
4.67
Baseline 3.92 hours · Performance 4.41 hours · Measure score 4.67 · Achievement 4.67 · Improvement 2.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.49% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 349 · Observed rate 8.88% · Lower 95% interval 6.93% |
| Discharge to community | 61.71% |
50.57%
11.1 pts better
|
Better than the National Rate · Eligible stays 337 · Observed rate 55.79% · Lower 95% interval 57.42% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.43% |
95.27%
3.2 pts better
|
Numerator 251 · Denominator 255 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 254 |
| Discharge self-care score | 42.54% |
53.69%
11.1 pts worse
|
Numerator 77 · Denominator 181 |
| Discharge mobility score | 45.3% |
50.94%
5.6 pts worse
|
Numerator 82 · Denominator 181 |
| Pressure ulcers or injuries, new or worsened | 0.78% |
2.29%
1.5 pts better
|
Numerator 2 · Denominator 255 · Adjusted rate 0.8% |
| Healthcare-associated infections requiring hospitalization | 8.48% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 214 · Observed rate 9.81% · Lower 95% interval 5.84% |
| Staff COVID-19 vaccination coverage | 23.04% |
8.2%
14.8 pts better
|
Numerator 44 · Denominator 191 |
| Staff flu vaccination coverage | 32.31% |
42%
9.7 pts worse
|
Numerator 63 · Denominator 195 |
| Discharge function score | 51.93% |
56.45%
4.5 pts worse
|
Numerator 94 · Denominator 181 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 68 · Denominator 68 |
| Transfer of health information to patient | 97.52% |
96.28%
1.2 pts better
|
Numerator 118 · Denominator 121 |
| Resident COVID-19 vaccinations up to date | 12.08% |
25.2%
13.1 pts worse
|
Numerator 18 · Denominator 149 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.5%
6.2 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
94.7%
3.3 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.4%
1.8 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.2% · Q3 2.2% · Q4 1.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
7.4%
4 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.9% · Q3 3.5% · Q4 1.1% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.0%
2 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 12.0% · Q3 6.5% · Q4 4.8% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.7% |
11.2%
6.5 pts better
|
19.6%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.5% · Q3 6.2% · Q4 5.6% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
20.6%
11.3 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.1% · Q3 10.4% · Q4 9.3% · 4Q avg 9.3% · 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 | 32.5% |
15.2%
17.3 pts worse
|
16.3%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.5% · Q2 22.7% · Q3 42.9% · Q4 21.0% · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.5% |
14.6%
9.9 pts worse
|
14.9%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 16.7% · Q3 24.7% · Q4 19.5% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.8%
0.4 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 2.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.5%
1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
22.4%
5.3 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 28.4% · Q3 28.0% · Q4 24.1% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
3.7%
0.9 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.8% · Q3 5.3% · Q4 1.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
76.4%
20.5 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.4% · Q3 95.0% · Q4 96.4% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
12.8%
4.2 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 8.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.4% |
75.6%
0.2 pts worse
|
79.7%
4.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
20.3%
2.6 pts worse
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 22.4% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-26 · Fire 2023-01-26
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-10-14 · Fire 2021-10-14
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-10
E · Potential for more than minimal harm
2023-01-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-26
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-26
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-10
D · Potential for more than minimal harm
2021-10-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-02
D · Potential for more than minimal harm
2021-10-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-07
D · Potential for more than minimal harm
2021-10-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-02
D · Potential for more than minimal harm
2021-10-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-02
Inspection history
Recent health citations
G · Actual harm
2025-06-19
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 2025-07-15
D · Potential for more than minimal harm
2025-06-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-15
E · Potential for more than minimal harm
2024-05-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-09
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 2024-07-02
E · Potential for more than minimal harm
2023-01-26
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 2023-03-09
D · Potential for more than minimal harm
2023-01-26
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 2023-03-09
D · Potential for more than minimal harm
2023-01-26
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 2023-03-09
D · Potential for more than minimal harm
2023-01-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-01-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-01-26
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-03-09
D · Potential for more than minimal harm
2021-10-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-11-17
Penalties and ownership
What sits behind the stars
Ownership
Sbk Capital, LLC
5% Or Greater Direct Ownership Interest · Organization
Clear Choice Health Care LLC
Operational/Managerial Control · Organization
Kennedy, Deborah
Operational/Managerial Control · Individual
Partee, Leslie
Corporate Officer · Individual
Peabody, Scott
Contracted Managing Employee · Individual
Sylvain, Thomas
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Suites At Holly Creek Care Center, The
Centennial, CO
5-star overall rating with 4-star inspections with $42,056 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Suites At Someren Glen Care Center, The
Centennial, CO
3-star overall rating with 3-star inspections with $36,446 in total fines with 8 recent health deficiencies
#3
Brookdale Greenwood Village
Greenwood Village, CO
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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