Cycle 1
Health 2024-11-07 · Fire 2024-11-07
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Englewood, CO
Englewood Post Acute And Rehabilitation
4-star overall rating with 4-star inspections with $17,696 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3575 S Washington St, Englewood, CO
(303) 789-2265
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1968-09-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.65
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,945
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.87
Baseline 20.21% · Performance 20.10% · Measure score 2.87 · Achievement 2.87 · Improvement 0
Healthcare-associated infections
0
Baseline 7.08% · Performance 8.54% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.24
Baseline 67.06% · Performance 38.60% · Measure score 6.24 · Achievement 6.14 · Improvement 6.24
Adjusted total nurse staffing
0.97
Baseline 3.52 hours · Performance 3.35 hours · Measure score 0.97 · Achievement 0.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 10.58% · Lower 95% interval 7.61% |
| Discharge to community | 52.84% |
50.57%
2.3 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 44.94% · Lower 95% interval 38.85% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 78 · Denominator 78 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 78 |
| Discharge self-care score | 62.75% |
53.69%
9.1 pts better
|
Numerator 32 · Denominator 51 |
| Discharge mobility score | 56.86% |
50.94%
5.9 pts better
|
Numerator 29 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 1.28% |
2.29%
1 pts better
|
Numerator 1 · Denominator 78 · Adjusted rate 1.12% |
| Healthcare-associated infections requiring hospitalization | 8.54% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 12.5% · Lower 95% interval 5.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | 98.9% |
42%
56.9 pts better
|
Numerator 179 · Denominator 181 |
| Discharge function score | 56.86% |
56.45%
0.4 pts better
|
Numerator 29 · Denominator 51 |
| Transfer of health information to provider | 97.56% |
95.95%
1.6 pts better
|
Numerator 40 · Denominator 41 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10.53% |
25.2%
14.7 pts worse
|
Numerator 4 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · 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 | 79.0% |
94.7%
15.7 pts worse
|
95.5%
16.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.4%
1.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.6% · Q4 3.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.4% |
7.4%
2 pts worse
|
11.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 23.6% · Q3 8.5% · Q4 3.4% · 4Q avg 9.4% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
5.0%
3.6 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 7.5% · Q3 6.8% · Q4 10.5% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
11.2%
3.3 pts worse
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 16.4% · Q3 13.3% · Q4 15.3% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
20.6%
7.1 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.8% · Q3 13.2% · Q4 16.7% · 4Q avg 13.5% · 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 | 26.0% |
15.2%
10.8 pts worse
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 51.7% · Q3 18.6% · Q4 8.1% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
14.6%
5.9 pts worse
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 53.8% · Q3 8.5% · Q4 8.8% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
22.4%
0.1 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 36.0% · Q3 16.8% · Q4 17.1% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
3.7%
3.3 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 6.2% · Q3 7.3% · Q4 3.7% · 4Q avg 7.0% · Used in QM five-star |
| 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 96.7% · Q2 99.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
12.8%
5.2 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.6% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.0% |
75.6%
5.6 pts worse
|
79.7%
9.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
20.3%
0.2 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 24.1% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-06 · Fire 2023-06-06
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-03-10 · Fire 2020-03-10
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-11-07
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-11-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-14
F · Potential for more than minimal harm
2023-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-06-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-06-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-21
F · Potential for more than minimal harm
2020-03-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-10-06
F · Potential for more than minimal harm
2020-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-10-12
F · Potential for more than minimal harm
2020-03-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-09-23
F · Potential for more than minimal harm
2020-03-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-09-23
F · Potential for more than minimal harm
2020-03-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-10-23
D · Potential for more than minimal harm
2020-03-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-09-03
D · Potential for more than minimal harm
2020-03-10
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 2020-10-06
D · Potential for more than minimal harm
2020-03-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-09-11
D · Potential for more than minimal harm
2020-03-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-10-19
D · Potential for more than minimal harm
2020-03-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-10-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-07
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-29
G · Actual harm
2023-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-06-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-06
F742 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2023-06-27
G · Actual harm
2020-03-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-20
G · Actual harm
2020-03-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-04-20
F · Potential for more than minimal harm
2020-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-20
E · Potential for more than minimal harm
2020-03-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-04-20
E · Potential for more than minimal harm
2020-03-10
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 2020-04-28
E · Potential for more than minimal harm
2020-03-10
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 2020-04-20
Penalties and ownership
What sits behind the stars
$17,696
2023-06-06
Fine
Fine · fine $17,696
Fine
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Christensen, Christopher
Corporate Director · Individual
Fisher, Candace
Operational/Managerial Control · Individual
Fisher, Candace
W-2 Managing Employee · Individual
Snapper, Suzanne
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Wellsprings Care Center
Englewood, CO
2-star overall rating with 1-star inspections with abuse icon flag with 19 recent health deficiencies
#2
Julia Temple Healthcare Center
Englewood, CO
3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
Suites At Clermont Park Care Center, The
Denver, CO
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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