Cycle 1
Health 2024-09-26 · Fire 2024-09-26
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Northglenn, CO
Malley Transitional Care Center
3-star overall rating with 2-star inspections with $32,003 in total fines with 6 recent health deficiencies
401 Malley Dr, Northglenn, CO
(303) 452-4700
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
162
Certified beds
Average residents
143
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1984-09-28
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
0.66
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.57
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,954
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
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
2.43
Baseline 8.87% · Performance 7.73% · Measure score 2.43 · Achievement 0 · Improvement 2.43
Total nurse turnover
6.06
Baseline 35.61% · Performance 38.93% · Measure score 6.06 · Achievement 6.06 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.36 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 6.01% |
| Discharge to community | 42.79% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 35% · Lower 95% interval 30.94% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 17 · Denominator 29 |
| Discharge mobility score | 44.83% |
50.94%
6.1 pts worse
|
Numerator 13 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.73% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 4.46% |
| Staff COVID-19 vaccination coverage | 8.89% |
8.2%
0.7 pts better
|
Numerator 20 · Denominator 225 |
| Staff flu vaccination coverage | 90.07% |
42%
48.1 pts better
|
Numerator 263 · Denominator 292 |
| Discharge function score | 68.97% |
56.45%
12.5 pts better
|
Numerator 20 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
93.5%
5.4 pts worse
|
93.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 86.9% · Q3 86.0% · Q4 90.6% · 4Q avg 88.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
94.7%
0.1 pts better
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.4%
1 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.5% · Q3 2.5% · Q4 1.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
7.4%
5 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.9% · Q3 1.0% · Q4 0.9% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.0%
2 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.8% · Q3 7.9% · Q4 6.6% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.5% |
11.2%
6.3 pts worse
|
19.6%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 17.2% · Q3 19.0% · Q4 19.8% · 4Q avg 17.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
20.6%
9.5 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 12.1% · Q3 8.7% · Q4 12.0% · 4Q avg 11.1% · 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 | 9.6% |
15.2%
5.6 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 20.2% · Q4 7.3% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
14.6%
0.7 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 18.6% · Q3 7.6% · Q4 14.1% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.8%
0.4 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.5%
0.9 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 3.4% · Q4 1.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
22.4%
3.8 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 29.1% · Q3 25.7% · Q4 24.3% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
3.7%
1.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.8% · Q3 4.4% · Q4 3.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.1% |
76.4%
13.3 pts worse
|
81.7%
18.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.7% · Q2 63.2% · Q3 66.0% · Q4 62.8% · 4Q avg 63.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
12.8%
1.8 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 16.7% · Expected 12.7% · Used in QM five-star |
| 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% · Q3 0.0% · Q4 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 | 47.2% |
75.6%
28.4 pts worse
|
79.7%
32.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.2% |
| 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 26.7% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
17 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-11-12 · Fire 2019-11-12
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-26
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 2024-10-25
D · Potential for more than minimal harm
2024-09-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-26
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 2024-10-25
D · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
G · Actual harm
2023-09-07
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 2023-10-03
K · Immediate jeopardy
2023-03-30
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 2023-04-28
G · Actual harm
2023-03-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
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 2023-04-28
F · Potential for more than minimal harm
2023-03-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
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 2023-05-05
E · Potential for more than minimal harm
2023-03-30
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 2023-05-05
E · Potential for more than minimal harm
2023-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-30
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 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
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 2023-05-05
D · Potential for more than minimal harm
2023-03-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-30
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
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 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-28
G · Actual harm
2019-11-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-17
F · Potential for more than minimal harm
2019-11-12
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 2019-12-13
E · Potential for more than minimal harm
2019-11-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-12-02
Penalties and ownership
What sits behind the stars
$11,180
2023-09-07
Fine
Fine · fine $11,180
Fine
$20,823
2023-03-30
Fine
Fine · fine $20,823
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
Burton, Spencer
Corporate Director · Individual
Fitch, Craig
Corporate Officer · Individual
Jorgensen, David
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Officer · Individual
Schnabel, Michael
Operational/Managerial Control · Individual
Schnabel, Michael
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Center At Northridge, LLC, The
Westminster, CO
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Villas At Sunny Acres, The
Thornton, CO
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
#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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