Cycle 1
Health 2024-12-19 · Fire 2024-12-19
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Westminster, CO
Village Care And Rehabilitation Center, The
4-star overall rating with 4-star inspections with 3 recent health deficiencies
9221 Wadsworth Pkwy, Westminster, CO
(303) 403-2900
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
1998-03-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 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
0.83
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.17
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.59
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,481
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9928
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.15
Baseline 5.77% · Performance 6.89% · Measure score 3.15 · Achievement 3.15 · Improvement 0
Total nurse turnover
4.63
Baseline 67.19% · Performance 45.45% · Measure score 4.63 · Achievement 4.46 · Improvement 4.63
Adjusted total nurse staffing
4.16
Baseline 3.67 hours · Performance 4.26 hours · Measure score 4.16 · Achievement 4.16 · Improvement 2.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.27% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 1.75% · Lower 95% interval 5.95% |
| Discharge to community | 55.32% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 57.69% · Lower 95% interval 46.9% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 33.33% |
95.27%
61.9 pts worse
|
Numerator 9 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 45.83% |
53.69%
7.9 pts worse
|
Numerator 11 · Denominator 24 |
| Discharge mobility score | 29.17% |
50.94%
21.8 pts worse
|
Numerator 7 · Denominator 24 |
| 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 | 6.89% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 3.07% |
| Staff COVID-19 vaccination coverage | 14.78% |
8.2%
6.6 pts better
|
Numerator 17 · Denominator 115 |
| Staff flu vaccination coverage | 74.58% |
42%
32.6 pts better
|
Numerator 132 · Denominator 177 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 8 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · 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 | 0.7 |
1.3
0.6 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.9 · 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 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
93.5%
10.6 pts worse
|
93.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.7% · Q2 87.2% · Q3 82.5% · Q4 88.6% · 4Q avg 82.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.6% |
94.7%
6.1 pts worse
|
95.5%
6.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.4%
0.8 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.0% · Q4 5.7% · 4Q avg 2.6% · 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 | 8.3% |
5.0%
3.3 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.7% · Q3 10.3% · Q4 7.4% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
11.2%
0.2 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 15.4% · Q3 13.8% · Q4 11.1% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
20.6%
14.9 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.8% · Q3 9.1% · Q4 4.3% · 4Q avg 5.7% · 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 | 35.2% |
15.2%
20 pts worse
|
16.3%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.1% |
14.6%
14.5 pts worse
|
14.9%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 24.0% · Q3 31.0% · Q4 36.4% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.8% |
0.8%
4 pts worse
|
1.0%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.0% · Q3 4.4% · Q4 4.5% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
22.4%
2.4 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 27.7% · Q3 23.0% · Q4 19.7% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
3.7%
2.9 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.9% · Q3 4.5% · Q4 2.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.2% |
76.4%
14.2 pts worse
|
81.7%
19.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.5% · Q2 56.7% · Q3 60.7% · Q4 67.7% · 4Q avg 62.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
12.8%
1.8 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 9.5% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 3.7% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.2% |
75.6%
15.4 pts worse
|
79.7%
19.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
20.3%
3.3 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 19.0% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-21 · Fire 2023-06-21
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-08
G · Actual harm
2024-10-08
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 2024-11-05
E · Potential for more than minimal harm
2023-06-21
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 2023-07-21
E · Potential for more than minimal harm
2023-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-21
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 2023-07-28
D · Potential for more than minimal harm
2023-06-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-14
E · Potential for more than minimal harm
2019-08-29
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 2019-10-11
E · Potential for more than minimal harm
2019-08-29
F920 · Environmental Deficiencies
Health
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Corrected 2019-10-11
E · Potential for more than minimal harm
2019-08-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-08-29
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-08-29
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 2019-10-11
Penalties and ownership
What sits behind the stars
Ownership
Covenant Living Communities & Services
5% Or Greater Direct Ownership Interest · Organization
Bentley, Sarah
Corporate Director · Individual
Christensen, Pamela
Corporate Director · Individual
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Davis, Kara
Corporate Director · Individual
Eastburg, Mark
Corporate Director · Individual
Erickson, David
Corporate Officer · Individual
Erickson, Rebekah
Corporate Officer · Individual
Holt, Jody
Operational/Managerial Control · Individual
Holt, Jody
Corporate Officer · Individual
Holt, Jody
W-2 Managing Employee · Individual
Kincannon, Kurt
Corporate Director · Individual
Manlove, Matt
Corporate Director · Individual
Martin, Robert
Corporate Director · Individual
Nelson, Richard
Corporate Director · Individual
Oxendale, Roger
Corporate Director · Individual
Rinard, Dale
Corporate Director · Individual
Vanover, Andrew
Corporate Director · Individual
Wenrich, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Westminster
Westminster, CO
4-star overall rating with 3-star inspections with $30,183 in total fines with 10 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Arbor View Care Center
Arvada, CO
4-star overall rating with 3-star inspections with $21,111 in total fines with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Clear Creek Care Center
Westminster, CO
3-star overall rating with 2-star inspections with 12 recent health deficiencies
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