Cycle 1
Health 2024-11-07 · Fire 2024-11-07
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Holyoke, CO
Regent Park Nursing And Rehabilitation
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
816 S Interocean Ave, Holyoke, CO
(970) 854-2251
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vivage Senior Living
Operator or chain grouping
Approved since
1992-09-14
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
0.35
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.50
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.38
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
0.88
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.23
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
31%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,840
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.16
Performance 19.51% · Measure score 4.16 · Achievement 4.16 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.27
Baseline 5.82% · Performance 6.86% · Measure score 3.27 · Achievement 3.27 · Improvement 0
Total nurse turnover
6.52
Performance 37.04% · Measure score 6.52 · Achievement 6.52 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.84 hours · Performance 2.79 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 8% · Lower 95% interval 6.99% |
| Discharge to community | 34.35% |
50.57%
16.2 pts worse
|
Worse than the National Rate · Eligible stays 59 · Observed rate 27.12% · Lower 95% interval 24.73% |
| Medicare spending per beneficiary | 1.63 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 52.17% |
53.69%
1.5 pts worse
|
Numerator 12 · Denominator 23 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 11 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 3.92% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 30 · Denominator 30 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 22 · Denominator 22 |
| Discharge function score | 60.87% |
56.45%
4.4 pts better
|
Numerator 14 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 1.9 |
1.3
0.6 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.7
1.4 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
93.5%
3.1 pts worse
|
93.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 89.5% · Q3 87.8% · Q4 87.5% · 4Q avg 90.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 55.0% |
94.7%
39.7 pts worse
|
95.5%
40.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 55.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.4%
0.4 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 4.9% · Q4 5.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
7.4%
7.4 pts better
|
11.4%
11.4 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 who lose too much weight | 2.0% |
5.0%
3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.5% · Q4 2.6% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.6% |
11.2%
8.6 pts better
|
19.6%
17 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 2.4% · Q4 2.5% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
20.6%
13.9 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 8.8% · Q3 5.9% · Q4 8.8% · 4Q avg 6.7% · 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 | 2.2% |
15.2%
13 pts better
|
16.3%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 3.5% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
14.6%
7.3 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 13.9% · Q3 10.0% · Q4 2.5% · 4Q avg 7.3% · 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 | 9.3% |
22.4%
13.1 pts better
|
19.8%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 7.1% · Q3 4.0% · Q4 0.0% · 4Q avg 9.3% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.9% |
76.4%
15.5 pts worse
|
81.7%
20.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 65.2% · Q4 60.7% · 4Q avg 60.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
12.8%
1.4 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 14.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.9% |
75.6%
13.7 pts worse
|
79.7%
17.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.3% |
20.3%
8 pts better
|
23.9%
11.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 10.7% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-21 · Fire 2023-06-21
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-11-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-12-16
F · Potential for more than minimal harm
2023-06-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-06-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-07
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 2024-11-20
D · Potential for more than minimal harm
2024-11-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-26
D · Potential for more than minimal harm
2023-06-21
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 2023-07-28
Penalties and ownership
What sits behind the stars
$8,469
2023-10-30
Fine
Fine · fine $8,469
Fine
Ownership
Brammeier, John
5% Or Greater Direct Ownership Interest · Individual
Brammeier, John
Corporate Officer · Individual
Koretke, Mary
W-2 Managing Employee · Individual
Kotch, Julie
Operational/Managerial Control · Individual
Moskowitz, Jay
5% Or Greater Direct Ownership Interest · Individual
Moskowitz, Jay
Corporate Officer · Individual
Qp Health Care Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Sedgwick County Memorial Nursing Home
Julesburg, CO
1-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Imperial Manor Nursing Home
Imperial, NE
2-star overall rating with 2-star inspections with $7,903 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Hillcrest Care Center
Wray, CO
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
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