Cycle 1
Health 2024-12-10 · Fire 2024-12-10
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Englewood, CO
Julia Temple Healthcare Center
3-star overall rating with 3-star inspections with 7 recent health deficiencies
3401 S Lafayette St, Englewood, CO
(303) 761-0075
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1994-04-15
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
0.59
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,902
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0078
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.47
Baseline 16.01% · Performance 18.90% · Measure score 5.47 · Achievement 5.47 · Improvement 0
Healthcare-associated infections
3.76
Baseline 5.00% · Performance 6.71% · Measure score 3.76 · Achievement 3.76 · Improvement 0
Total nurse turnover
8.22
Baseline 28.30% · Performance 30.09% · Measure score 8.22 · Achievement 8.22 · Improvement 0
Adjusted total nurse staffing
3.81
Baseline 4 hours · Performance 4.16 hours · Measure score 3.81 · Achievement 3.81 · Improvement 0.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 181 · Observed rate 6.08% · Lower 95% interval 6.88% |
| Discharge to community | 46.01% |
50.57%
4.6 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 44.52% · Lower 95% interval 40.42% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.18% |
95.27%
4.1 pts worse
|
Numerator 93 · Denominator 102 |
| Falls with major injury | 0.98% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 102 |
| Discharge self-care score | 65.43% |
53.69%
11.7 pts better
|
Numerator 53 · Denominator 81 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 54 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 0.98% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 102 · Adjusted rate 0.98% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 4.76% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 0.52% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 194 |
| Staff flu vaccination coverage | 93.05% |
42%
51 pts better
|
Numerator 174 · Denominator 187 |
| Discharge function score | 76.54% |
56.45%
20.1 pts better
|
Numerator 62 · Denominator 81 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 29 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 8 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
93.5%
5.7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.7%
3.4 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.4%
2.2 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.5% · Q3 4.5% · Q4 3.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.4% |
7.4%
7 pts worse
|
11.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 16.9% · Q3 19.5% · Q4 4.7% · 4Q avg 14.4% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
5.0%
5.9 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 12.9% · Q3 17.1% · Q4 9.1% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.4% |
11.2%
9.8 pts better
|
19.6%
18.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.1% · Q3 1.2% · Q4 1.1% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.5% |
20.6%
2.1 pts better
|
16.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 20.9% · Q3 17.1% · Q4 19.7% · 4Q avg 18.5% · 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 | 15.9% |
15.2%
0.7 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 24.3% · Q3 22.4% · Q4 4.3% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
14.6%
0.5 pts worse
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 20.9% · Q3 17.3% · Q4 3.5% · 4Q avg 15.1% · 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 | 0.9% |
1.5%
0.6 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
22.4%
2.9 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 33.8% · Q3 29.5% · Q4 21.0% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
3.7%
0.9 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.3% · Q3 4.1% · Q4 1.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
76.4%
19.4 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 97.8% · Q3 95.9% · Q4 93.0% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
12.8%
0.3 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 14.1% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 3.8% · Q4 4.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
75.6%
11.1 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
20.3%
5.1 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 24.7% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-05-12 · Fire 2022-05-12
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-12-10
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-12-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-10
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 2025-01-10
D · Potential for more than minimal harm
2024-12-10
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-10
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 2025-01-10
E · Potential for more than minimal harm
2023-07-27
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 2023-08-18
D · Potential for more than minimal harm
2023-07-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-27
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-04-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-10
Penalties and ownership
What sits behind the stars
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Boyles, Eddy
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Dunyon, David
Corporate Officer · Individual
Gahm, Gregory
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Englewood Post Acute And Rehabilitation
Englewood, CO
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
#2
Wellsprings Care Center
Englewood, CO
2-star overall rating with 1-star inspections with abuse icon flag with 19 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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