Cycle 1
Health 2024-04-02 · Fire 2024-04-02
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Westminster, CO
Center At Northridge, LLC, The
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
12285 Pecos St, Westminster, CO
(303) 280-4444
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Veritas Management Group
Operator or chain grouping
Approved since
2016-06-27
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 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
0.95
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.22
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,224
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9937
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.90
Baseline 20.03% · Performance 20.09% · Measure score 2.90 · Achievement 2.90 · Improvement 0
Healthcare-associated infections
10
Baseline 6.25% · Performance 4.38% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
2.25
Baseline 47.66% · Performance 54.48% · Measure score 2.25 · Achievement 2.25 · Improvement 0
Adjusted total nurse staffing
1.18
Baseline 4.13 hours · Performance 3.41 hours · Measure score 1.18 · Achievement 1.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 679 · Observed rate 8.84% · Lower 95% interval 7.91% |
| Discharge to community | 68.04% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 698 · Observed rate 66.19% · Lower 95% interval 65.22% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.78% |
95.27%
4.5 pts better
|
Numerator 449 · Denominator 450 |
| Falls with major injury | 0.44% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 450 |
| Discharge self-care score | 64.41% |
53.69%
10.7 pts better
|
Numerator 219 · Denominator 340 |
| Discharge mobility score | 74.12% |
50.94%
23.2 pts better
|
Numerator 252 · Denominator 340 |
| Pressure ulcers or injuries, new or worsened | 0.67% |
2.29%
1.6 pts better
|
Numerator 3 · Denominator 450 · Adjusted rate 0.76% |
| Healthcare-associated infections requiring hospitalization | 4.38% |
7.12%
2.7 pts better
|
Better than the National Rate · Eligible stays 439 · Observed rate 2.73% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 16.83% |
8.2%
8.6 pts better
|
Numerator 52 · Denominator 309 |
| Staff flu vaccination coverage | 77.22% |
42%
35.2 pts better
|
Numerator 305 · Denominator 395 |
| Discharge function score | 62.94% |
56.45%
6.5 pts better
|
Numerator 214 · Denominator 340 |
| Transfer of health information to provider | 97.81% |
95.95%
1.9 pts better
|
Numerator 357 · Denominator 365 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 83 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 30.9% |
25.2%
5.7 pts better
|
Numerator 72 · Denominator 233 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
76.4%
22.6 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.3% · Q3 99.0% · Q4 98.5% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
12.8%
5 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.2% · Q3 0.5% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
75.6%
16.9 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
20.3%
1.4 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 19.1% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-10 · Fire 2023-01-10
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-09-30 · Fire 2021-09-30
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-02
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-04-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-04-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-04-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-04-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-04-02
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 2024-06-18
F · Potential for more than minimal harm
2024-04-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-04-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-04-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-04-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-04-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-18
F · Potential for more than minimal harm
2023-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-02
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-02
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 2024-05-10
E · Potential for more than minimal harm
2023-01-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-02-10
F · Potential for more than minimal harm
2021-09-30
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 2021-10-20
F · Potential for more than minimal harm
2021-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-28
E · Potential for more than minimal harm
2021-09-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-10-20
E · Potential for more than minimal harm
2021-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-20
E · Potential for more than minimal harm
2021-09-30
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 2021-10-20
D · Potential for more than minimal harm
2021-09-30
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-30
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-30
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 2021-10-20
D · Potential for more than minimal harm
2021-09-30
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-30
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 2021-10-20
Penalties and ownership
What sits behind the stars
Ownership
Esmas, Bartolome
Corporate Director · Individual
Murdock, Monte
Operational/Managerial Control · Individual
Smith, Edward
Corporate Officer · Individual
Nearby options
Other facilities in reach
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#2
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2-star overall rating with 1-star inspections with abuse icon flag with $72,937 in total fines with 14 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
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4-star overall rating with 3-star inspections with $19,988 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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