Cycle 1
Health 2024-12-19 · Fire 2024-12-19
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fort Morgan, CO
Valley View Villa
5-star overall rating with 5-star inspections with $7,443 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
815 Fremont Ave, Fort Morgan, CO
(970) 867-8261
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
120
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1990-01-01
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
1.41
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.19
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.19
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
1.60
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.07
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
1.56
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
7%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,276
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.31
Baseline 19.11% · Performance 17.58% · Measure score 8.31 · Achievement 8.31 · Improvement 6.84
Healthcare-associated infections
1.91
Baseline 5.68% · Performance 7.26% · Measure score 1.91 · Achievement 1.91 · Improvement 0
Total nurse turnover
3.62
Baseline 39.39% · Performance 48.89% · Measure score 3.62 · Achievement 3.62 · Improvement 0
Adjusted total nurse staffing
2.41
Baseline 3.85 hours · Performance 3.76 hours · Measure score 2.41 · Achievement 2.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.77% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 6.77% |
| Discharge to community | 53.63% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 50.63% · Lower 95% interval 45.46% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 72.41% |
53.69%
18.7 pts better
|
Numerator 21 · Denominator 29 |
| Discharge mobility score | 68.97% |
50.94%
18 pts better
|
Numerator 20 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.26% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 31.08% |
8.2%
22.9 pts better
|
Numerator 23 · Denominator 74 |
| Staff flu vaccination coverage | 86.14% |
42%
44.1 pts better
|
Numerator 87 · Denominator 101 |
| Discharge function score | 72.41% |
56.45%
16 pts better
|
Numerator 21 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 31.82% |
25.2%
6.6 pts better
|
Numerator 7 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 5.1% |
3.4%
1.7 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.3% · Q3 3.8% · Q4 6.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
7.4%
2.1 pts better
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 3.4% · Q3 4.0% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.0%
1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.0% · Q3 0.0% · Q4 3.3% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.6% |
11.2%
6.6 pts better
|
19.6%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 8.3% · Q4 6.7% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.4% |
20.6%
14.2 pts better
|
16.7%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.5% · Q3 5.0% · Q4 11.1% · 4Q avg 6.4% · 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 | 9.3% |
15.2%
5.9 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
14.6%
4.6 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 8.0% · Q3 9.1% · Q4 10.7% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.3% |
0.8%
3.5 pts worse
|
1.0%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.5% · Q3 4.9% · Q4 3.6% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.5%
0.6 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.1% |
22.4%
7.3 pts better
|
19.8%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 31.6% · Q3 17.6% · Q4 6.5% · 4Q avg 15.1% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
3.7%
2.6 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 13.8% · Q3 12.0% · Q4 0.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
76.4%
23.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.5% |
12.8%
8.3 pts better
|
12.0%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 3.7% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.4% |
75.6%
21.8 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
20.3%
4.7 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 18.5% · Expected 17.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-08-06 · Fire 2019-08-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
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 2025-01-29
F · Potential for more than minimal harm
2024-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-14
F · Potential for more than minimal harm
2024-12-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-14
F · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-14
F · Potential for more than minimal harm
2024-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-14
E · Potential for more than minimal harm
2024-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-14
D · Potential for more than minimal harm
2024-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-31
F · Potential for more than minimal harm
2023-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-05
E · Potential for more than minimal harm
2023-08-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-08-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-08-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-08-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-08-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-25
D · Potential for more than minimal harm
2019-08-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-10
D · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-27
G · Actual harm
2023-08-17
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 2023-06-01
F · Potential for more than minimal harm
2019-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-29
D · Potential for more than minimal harm
2019-08-06
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 2019-09-15
Penalties and ownership
What sits behind the stars
$7,443
2023-08-17
Fine
Fine · fine $7,443
Fine
Ownership
Consolidated Resources Health Care Fund I LP
5% Or Greater Direct Ownership Interest · Organization
Cross, Cindy
Corporate Officer · Individual
Fletcher, Todd
Corporate Director · Individual
Fletcher, Todd
Corporate Officer · Individual
Fricke, Rhonda
Operational/Managerial Control · Individual
Fund I Investments Limited Partnership
5% Or Greater Indirect Ownership Interest · Organization
Henry, Terry
Corporate Officer · Individual
Lay, Lisa
Corporate Director · Individual
Lay, Lisa
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Preston, Aubrey
Operational/Managerial Control · Individual
Preston, Forrest
5% Or Greater Indirect Ownership Interest · Individual
Preston, Forrest
Operational/Managerial Control · Individual
Schmidt, Derek
Operational/Managerial Control · Individual
Swanker, Richard
Corporate Director · Individual
Swanker, Richard
Corporate Officer · Individual
Thurmond, Joan
Corporate Officer · Individual
Underwood, Jana
Operational/Managerial Control · Individual
Valley View Villa Opcm, Inc.
Operational/Managerial Control · Organization
Ziegler, James
Corporate Director · Individual
Ziegler, James
Corporate Officer · Individual
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