Cycle 1
Health 2024-01-09 · Fire 2024-01-09
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Littleton, CO
Littleton Care And Rehabilitation Center
4-star overall rating with 4-star inspections with $7,781 in total fines with 3 recent health deficiencies
5822 S Lowell Way, Littleton, CO
(303) 798-2497
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
35
Certified beds
Average residents
31
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1994-04-01
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
1.05
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.61
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
0.74
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
1.03
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
43%
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
11,465
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.09% · Performance 22.26% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.75% · Performance 8.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.32
Baseline 55.00% · Performance 41.94% · Measure score 5.32 · Achievement 5.32 · Improvement 3.83
Adjusted total nurse staffing
1.36
Baseline 3.39 hours · Performance 3.46 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 181 · Observed rate 11.05% · Lower 95% interval 8.39% |
| Discharge to community | 54.79% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 53.42% · Lower 95% interval 47.11% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.69% |
95.27%
1.4 pts better
|
Numerator 117 · Denominator 121 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 121 |
| Discharge self-care score | 37.97% |
53.69%
15.7 pts worse
|
Numerator 30 · Denominator 79 |
| Discharge mobility score | 44.3% |
50.94%
6.6 pts worse
|
Numerator 35 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 2.48% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 121 · Adjusted rate 2.73% |
| Healthcare-associated infections requiring hospitalization | 8.12% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 8.18% · Lower 95% interval 4.6% |
| Staff COVID-19 vaccination coverage | 5.36% |
8.2%
2.8 pts worse
|
Numerator 3 · Denominator 56 |
| Staff flu vaccination coverage | 96.67% |
42%
54.7 pts better
|
Numerator 87 · Denominator 90 |
| Discharge function score | 49.37% |
56.45%
7.1 pts worse
|
Numerator 39 · Denominator 79 |
| Transfer of health information to provider | 97.92% |
95.95%
2 pts better
|
Numerator 94 · Denominator 96 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.12% |
25.2%
1.9 pts better
|
Numerator 16 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| 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 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
7.4%
7.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.0%
3.9 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
11.2%
0.7 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
20.6%
20.6 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.1% |
15.2%
7.1 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
14.6%
8 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.8%
1.3 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
1.5%
3.8 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.0% |
22.4%
9.4 pts better
|
19.8%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% |
| 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 · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
76.4%
21.2 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 98.6% · Q3 97.4% · Q4 96.8% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
12.8%
7.1 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 5.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
75.6%
17.7 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
20.3%
3.9 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 22.5% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-14 · Fire 2022-09-14
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-10-30 · Fire 2019-10-30
4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-10-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-11-21
Inspection history
Recent health citations
G · Actual harm
2024-10-03
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 2024-10-21
E · Potential for more than minimal harm
2024-10-03
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-21
C · Minimal harm
2024-10-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-09-07
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 2023-05-26
D · Potential for more than minimal harm
2022-09-14
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 2022-10-04
D · Potential for more than minimal harm
2022-09-14
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-10-04
E · Potential for more than minimal harm
2019-10-30
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 2019-11-18
C · Minimal harm
2019-10-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-11-14
C · Minimal harm
2019-10-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-11-18
Penalties and ownership
What sits behind the stars
$7,781
2024-10-03
Fine
Fine · fine $7,781
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
Dunyon, David
Corporate Officer · Individual
Horton, Christopher
Operational/Managerial Control · Individual
Jorgensen, David
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Onshift Inc
Operational/Managerial Control · Organization
Port, Barry
Corporate Director · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Hallmark Nursing Center
Denver, CO
3-star overall rating with 3-star inspections with $6,788 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Cherrelyn Healthcare Center
Littleton, CO
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Littleton
Littleton, CO
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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