Overall Score
CMS Five-Star Quality RatingAverageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- ColoradoAbove only 41% of peers208 rated homes · average 3.1★
- Jefferson CountyAbove only 41% of peers23 rated homes · average 3.0★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.7 vs CO avg
- StaffingCan add or remove a star3★−0.1 vs CO avg
- Quality measuresCan add or remove a star5★+0.8 vs CO avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 20% of peersCO avg2.7★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 31% of peersCO avg3.1★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 50% of peersCO avg4.2★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.22hrsAbove only 31% of peersCO avg3.73Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.68hrsAbove only 40% of peersCO avg0.83Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better28%Top 7%CO avg49%RN turnover24%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$1,576Above 61% of peersCO avg$25,587Fines · denials1 · 0
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles36citations
4inspection dates
3actual harm (G–I)
0immediate jeopardy (J–L)
Sep 26, 2024most recent
Citations by monthFeb 2022 – Sep 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 26, 2024Cycle 1worst E · no actual harm
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Oct 25, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 25, 2024
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Oct 25, 2024
- F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Oct 25, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 25, 2024
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Oct 25, 2024
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Oct 25, 2024
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 25, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 25, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Oct 25, 2024
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Oct 25, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 25, 2024
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Oct 25, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 25, 2024
- F742Provide 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.Quality of Life and CareD · isolatedCorrected Oct 25, 2024
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Oct 25, 2024
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Oct 25, 2024
May 9, 2023Cycle 2worst G · actual harm$1,576
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected May 11, 2023
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected May 11, 2023
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsE · patternCorrected May 11, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 11, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected May 11, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 11, 2023
- F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected May 11, 2023
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected May 11, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 11, 2023
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected May 11, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected May 11, 2023
Feb 28, 2023Cycle 3worst D · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Mar 17, 2023
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 17, 2023
Feb 7, 2022Cycle 3worst G · actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 15, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Feb 15, 2022
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareE · patternCorrected Feb 15, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Feb 15, 2022
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareE · patternCorrected Feb 15, 2022
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Feb 15, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.22hrs
- Registered nursesRN hours only0.68hrs
- Licensed practical nursesLPN hours0.62hrs
- Nurse aidesCNA hours1.91hrs
- Weekend nursingAll staff on Saturdays and Sundays2.76hrs
- Colorado average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better28%Top 7%CO avg 49%
- RN turnoverRegistered nurses only24%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy125 certified beds · ~108 residents a day86%Above 58% of peersCO avg 79%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $1,576In fines
- 1Fine
- 0Payment denials
- $25,587CO avg in fines
Above 61% of peersFewer fines than 61% of rated homes in Colorado
Actions on record
- May 9, 2023Civil money penalty$1,576
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Vivage Senior Living17 facilities in the chain3.3★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Jay Moskowitz
Operational or managerial control
- Qp Health Care Services LLC
Corporate officers
- John Brammeier
- Jay Moskowitz
Managing employees
- Frances Holliday
- Mary Koretke
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 065298 · 1655 YARROW ST, LAKEWOOD, CO, 80214.
- Percentiles compare this facility with every rated nursing home in Colorado and Jefferson County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
