Emmaus Catholic Hospice
A hospice in Greenwood Village, Colorado 80111
6160 S Syracuse Way, Ste 250, Greenwood Village, Colorado 80111. (303) 322-1413.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 3 deficiencies cited in the last three years
- Not rated family caregiver rating
- 8of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
3 deficiencies cited in the last three years
The middle of the 35 hospices serving ZIP code 80111 had 5.
The last inspection on record was on Sep 11, 2026: a reaccreditation inspection by the Community Health Accreditation Partner.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
3 deficiencies in 1 month of the last 36. Last cited Sep 2026. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Sep 11, 2026: reaccreditation inspection by the Community Health Accreditation Partner3 deficiencies
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Coordination of services (42 CFR 418.112(e)(3)(i))
The inspectors’ words, 235 words
“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the most recent hospice plan of care. This standard was not met as evidenced by document review, interview and observation. In 1 of 1 (100%) observations of a patient who resided in an SNF/NF the agency did not ensure that a copy of the most recent hospice plan of care was provided to the SNF/NF. HOME VISIT 1: The patient elected the hospice benefit on March 13, 2026, and resided in a skilled nursing facility. An observation visit occurred on September 10, 2026, with the registered nurse case manager. The hospice had provided a binder with information, including access to the hospice 24-hour on-call system and names and contact information for hospice staff. However, the most recent hospice plan of care was not provided to the facility. An interview was conducted with the Director of Clinical Services on September 11, 2026. to review the home visit and findings. The Clinical Director stated that documentation is provided only when the facility agrees to have forms on file. She stated that this facility has not requested hard copy forms. An interview was conducted with the CEO/Administrator on September 11, 2026. After a review of the findings, she stated she was going to conduct an in-service on these specific requirements this week. She acknowledged the agency had not provided facilities with the required documentation.”
-
Coordination of services (42 CFR 418.112(e)(3)(ii))
The inspectors’ words, 232 words
“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the hospice election form and any advance directives. This standard was not met as evidenced by document review, interview and observation. In 1 of 1 (100%) observation of a patient who resides in an SNF/NF: the agency did not ensure that a copy of the patient’s election of hospice benefit. HOME VISIT 1: The patient elected the hospice benefit on March 13, 2026, and resided in a skilled nursing facility. An observation visit occurred on September 10, 2026, with the registered nurse case manager. The hospice had provided a binder with information, including access to the hospice 24-hour on-call system and names and contact information for hospice staff. However, a copy of the patient’s election of hospice benefit was not provided to the facility. An interview was conducted with the Director of Clinical Services on September 11, 2026. to review the home visit and findings. The Clinical Director stated that documentation is provided only when the facility agrees to have forms on file. She stated that this facility has not requested hard copy forms. An interview was conducted with the CEO/Administrator on September 11, 2026. After a review of the findings, she stated she was going to conduct an in-service on these specific requirements this week. She acknowledged the agency had not provided facilities with the required documentation.”
-
Coordination of services (42 CFR 418.112(e)(3)(iii))
The inspectors’ words, 239 words
“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident the physician certification and recertification of the terminal illness. This standard was not met as evidenced by document review, interview and observation. In 1 of 1 (100%) observation of a patient who resides in an SNF/NF: the agency did not ensure that a copy of the physician’s certification of terminal illness. HOME VISIT 1: The patient elected the hospice benefit on March 13, 2026, and resided in a skilled nursing facility. An observation visit occurred on September 10, 2026, with the registered nurse case manager. The hospice had provided a binder with information, including access to the hospice 24-hour on-call system and names and contact information for hospice staff. However, a copy of the physician’s certification of terminal illness was not provided to the facility. An interview was conducted with the Director of Clinical Services on September 11, 2026. to review the home visit and findings. The Clinical Director stated that documentation is provided only when the facility agrees to have forms on file. She stated that this facility has not requested hard copy forms. An interview was conducted with the CEO/Administrator on September 11, 2026. After a review of the findings, she stated she was going to conduct an in-service on these specific requirements this week. She acknowledged the agency had not provided facilities with the required documentation.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Sep 11, 2026 | Reaccreditation inspection by the Community Health Accreditation Partner | 3 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Oct 13, 2023.
- CMS doesn’t list its type of ownership.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 13.1 nurse care minutes per routine home care day, 4.7% of skilled nursing minutes at weekends and a visit near death for 94.4% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 49% at home, 41% in assisted living, 10% in a skilled nursing facility.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 13.1 min |
| Skilled nursing minutes at weekends | 4.7% |
| Visits near death | 94.4% of patients who died |
Who owns it?
- 12 owners or officers are people: Victoria Owens (managing employee (on the payroll), 50%); Victoria Owens (corporate officer, 18%); Kelly Kozeliski (corporate director, 18%); Susan Swanson (managing employee (on the payroll), 10%); Brian A Macaulay (corporate director, 8%); Alan Rastrelli (corporate director, 8%); John Kelly (corporate director, 8%); Louis Morrone (corporate director, 8%); Katrin Rothgery (corporate director, 8%); David Wright (corporate director, 8%); Lynn Grandon (corporate director, 8%); Lyle Klimesh (corporate director, 8%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS’s Hospice Care Index: 8 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 98.61% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 8 of 10 |
How does it compare nearby?
- Of the 35 hospices CMS’s data show serving patients in ZIP code 80111, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 5; this one had 3.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| HCA Healthone Hospice & Family Care | 16 |
| Bristol Hospice - Denver | 0 |
| Colorado Palliative & Hospice Care, LLC | 37 |
| Advanced Hospice of Colorado | 5 |
| Choice Hospice | 6 |
| Silver Linings Hospice | 1 |
| Colorado Palliative & Hospice Care of the Front Range LLC | 0 |
| Sun Care Hospice Inc. | 32 |
| Emmaus Catholic Hospice This hospice | 3 |
| Med Care Hospice Inc. | 2 |
| Lily Hospice Care Inc. | 2 |
| Aurora Palliative and Hospice Care Inc. | 1 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.