Cycle 1
Health 2023-12-14 · Fire 2023-12-14
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Commerce City, CO
Irondale Post Acute
1-star overall rating with 1-star inspections with Special Focus status with $97,055 in total fines with 13 recent health deficiencies
7150 Poplar St, Commerce City, CO
(303) 289-7110
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1994-02-01
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
0.50
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,756
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.65
Baseline 37.50% · Performance 56.92% · Measure score 1.65 · Achievement 1.65 · Improvement 0
Adjusted total nurse staffing
2.19
Baseline 3.77 hours · Performance 3.7 hours · Measure score 2.19 · Achievement 2.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.02% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 6.06% |
| Discharge to community | 46.56% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 32% · Lower 95% interval 32.64% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | 94.12% |
42%
52.1 pts better
|
Numerator 128 · Denominator 136 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
93.5%
0.4 pts worse
|
93.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 100.0% · Q3 93.4% · Q4 84.9% · 4Q avg 93.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.0% |
94.7%
3.7 pts worse
|
95.5%
4.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.4%
0.4 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 3.9% · Q4 2.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
7.4%
4.4 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 8.1% · Q3 1.4% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.0%
2.3 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.5% · Q3 5.8% · Q4 6.5% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
11.2%
4.4 pts worse
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 14.3% · Q3 15.9% · Q4 16.1% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 42.3% |
20.6%
21.7 pts worse
|
16.7%
25.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 40.4% · Q3 46.8% · Q4 42.2% · 4Q avg 42.3% · 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 | 22.9% |
15.2%
7.7 pts worse
|
16.3%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.3% · Q2 26.8% · Q3 9.5% · Q4 17.5% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.0% |
14.6%
20.4 pts worse
|
14.9%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.8% · Q2 35.0% · Q3 41.8% · Q4 16.7% · 4Q avg 35.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.8%
0.7 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.4% · Q3 1.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.5%
1.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
22.4%
2.7 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 26.8% · Q3 27.3% · Q4 21.2% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
3.7%
0.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 3.5% · Q4 4.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.7% |
76.4%
20.7 pts worse
|
81.7%
26 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.1% · Q2 57.4% · Q3 64.4% · Q4 51.5% · 4Q avg 55.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.6% |
75.6%
33 pts worse
|
79.7%
37.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-01 · Fire 2022-09-01
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-02-13 · Fire 2020-02-13
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-12-23
L · Immediate jeopardy
2025-10-09
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 2025-11-11
F · Potential for more than minimal harm
2025-10-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-11-11
J · Immediate jeopardy
2025-04-30
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 2025-01-28
G · Actual harm
2024-11-20
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 2024-09-12
G · Actual harm
2023-12-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-12-14
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 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
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 2024-02-14
D · Potential for more than minimal harm
2023-12-14
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 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-09-13
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-03-06
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 2023-04-03
D · Potential for more than minimal harm
2023-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-03
D · Potential for more than minimal harm
2023-03-06
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 2023-04-03
D · Potential for more than minimal harm
2023-03-06
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-04-03
G · Actual harm
2022-09-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-09-01
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 2022-09-09
E · Potential for more than minimal harm
2020-02-13
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 2020-03-19
D · Potential for more than minimal harm
2020-02-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-03-24
D · Potential for more than minimal harm
2020-02-13
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2020-03-19
D · Potential for more than minimal harm
2020-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-24
D · Potential for more than minimal harm
2020-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-19
D · Potential for more than minimal harm
2020-02-13
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 2020-03-19
Penalties and ownership
What sits behind the stars
$46,270
2025-10-09
Fine
Fine · fine $46,270
Fine
$17,345
2025-04-30
Fine
Fine · fine $17,345
Fine
$8,338
2024-11-20
Fine
Fine · fine $8,338
Fine
$25,102
2023-12-14
Fine
Fine · fine $25,102
Fine
$0
2023-12-14
Payment Denial
Payment Denial · denial start 2024-01-13 · 32 days
32 day denial
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
Englade, Keith
Operational/Managerial Control · Individual
Graham, Joseph
Corporate Officer · Individual
Horton, Christopher
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Director · Individual
Kare Technologies LLC
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Prime Time Healthcare LLC
Operational/Managerial Control · Organization
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Ridgeview Post Acute
Commerce City, CO
3-star overall rating with 2-star inspections with abuse icon flag with 5 recent health deficiencies
#2
City Scape Rehabilitation & Care Center LLC
Denver, CO
2-star overall rating with 1-star inspections with abuse icon flag with $80,637 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Thornton Care Center
Thornton, CO
2-star overall rating with 1-star inspections with abuse icon flag with $21,483 in total fines with 25 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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