Cycle 1
Health 2025-07-24 · Fire 2025-07-24
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Colorado Springs, CO
Sunny Vista Living Center
3-star overall rating with 3-star inspections with 6 recent health deficiencies
2445 E Cache La Poudre St, Colorado Springs, CO
(719) 471-8700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
111
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-09-01
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
0.54
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,753
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.09
Baseline 22.13% · Performance 19.79% · Measure score 4.09 · Achievement 3.54 · Improvement 4.09
Healthcare-associated infections
3.37
Baseline 6.53% · Performance 6.83% · Measure score 3.37 · Achievement 3.37 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.39
Baseline 1.80 hours · Performance 4.15 hours · Measure score 5.39 · Achievement 3.75 · Improvement 5.39
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 4.94% · Lower 95% interval 6.05% |
| Discharge to community | 50.48% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 47.95% · Lower 95% interval 42.54% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.73% |
95.27%
2.5 pts worse
|
Numerator 51 · Denominator 55 |
| Falls with major injury | 3.64% |
0.77%
2.9 pts worse
|
Numerator 2 · Denominator 55 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 24 · Denominator 42 |
| Discharge mobility score | 45.24% |
50.94%
5.7 pts worse
|
Numerator 19 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 55 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 2.07% |
8.2%
6.1 pts worse
|
Numerator 3 · Denominator 145 |
| Staff flu vaccination coverage | 91.07% |
42%
49.1 pts better
|
Numerator 153 · Denominator 168 |
| Discharge function score | 54.76% |
56.45%
1.7 pts worse
|
Numerator 23 · Denominator 42 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 14.81% |
25.2%
10.4 pts worse
|
Numerator 4 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.8 · 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 | 84.9% |
93.5%
8.6 pts worse
|
93.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 90.7% · Q3 86.7% · Q4 89.7% · 4Q avg 84.9% |
| 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 | 3.4% |
3.4%
About the same
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.5% · Q3 4.4% · Q4 2.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
7.4%
3.6 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.3% · Q3 6.6% · Q4 4.9% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.0%
1.7 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.2% · Q3 10.1% · Q4 2.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
11.2%
3.8 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 5.7% · Q3 6.9% · Q4 7.2% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
20.6%
9.9 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.1% · Q3 13.6% · Q4 10.3% · 4Q avg 10.7% · 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 | 19.3% |
15.2%
4.1 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 7.1% · Q3 31.2% · Q4 24.8% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
14.6%
4.6 pts worse
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 8.2% · Q3 35.5% · Q4 23.0% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.8%
0.1 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.5%
0.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.1% · Q4 3.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
22.4%
About the same
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 27.8% · Q3 19.3% · Q4 28.9% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
3.7%
0.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.1% · Q3 1.0% · Q4 1.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
76.4%
22.4 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 97.9% · Q4 98.7% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
12.8%
3.1 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 9.1% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 2.4% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
75.6%
11.5 pts better
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
20.3%
3.1 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 18.2% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-30
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 2023-12-22
E · Potential for more than minimal harm
2022-08-11
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 2022-09-10
D · Potential for more than minimal harm
2022-08-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-24
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 2025-09-06
E · Potential for more than minimal harm
2025-07-24
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-06
E · Potential for more than minimal harm
2025-07-24
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 2025-09-06
D · Potential for more than minimal harm
2025-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-06
D · Potential for more than minimal harm
2025-07-24
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-09-06
D · Potential for more than minimal harm
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-06
D · Potential for more than minimal harm
2024-09-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-04
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-10-11
F · Potential for more than minimal harm
2023-11-30
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 2023-12-24
F · Potential for more than minimal harm
2023-11-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-30
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-12-22
E · Potential for more than minimal harm
2022-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
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 2022-09-22
D · Potential for more than minimal harm
2022-08-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-09-22
D · Potential for more than minimal harm
2022-08-11
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 2022-09-22
D · Potential for more than minimal harm
2022-08-11
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 2022-09-22
Penalties and ownership
What sits behind the stars
Ownership
Sunny Vista Living Center
5% Or Greater Direct Ownership Interest · Organization
Cappella Living Solutions
Operational/Managerial Control · Organization
Trout, Jeffrey
Operational/Managerial Control · Individual
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