20 health deficiencies
Top issue: Administration (6 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Windsor, CO
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $42,860 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
710 3rd St, Windsor, CO
(970) 686-7474
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
104
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1990-06-01
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
RN hours / resident day
0.83
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.42
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
0
Baseline 67.03% · Performance 82.29% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.52 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 5.67% |
| Discharge to community | 38.83% |
50.57%
11.7 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 24% · Lower 95% interval 26.22% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · 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 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 56.86% |
42%
14.9 pts better
|
Numerator 87 · Denominator 153 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.5 · 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 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
93.5%
1 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 94.0% · Q3 95.0% · Q4 97.4% · 4Q avg 94.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
94.7%
1 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.4%
0.9 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.8% · Q3 5.0% · Q4 2.6% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
7.4%
5.2 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 2.9% · Q4 1.5% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
5.0%
3.8 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.6% · Q3 10.0% · Q4 6.2% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
11.2%
3.8 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.5% · Q3 7.1% · Q4 4.6% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.5% |
20.6%
19.9 pts worse
|
16.7%
23.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.6% · Q2 37.7% · Q3 44.4% · Q4 36.7% · 4Q avg 40.5% · 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 | 34.1% |
15.2%
18.9 pts worse
|
16.3%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.0% · Q2 42.2% · Q3 23.0% · Q4 18.2% · 4Q avg 34.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.2% |
14.6%
19.6 pts worse
|
14.9%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.6% · Q2 51.5% · Q3 16.1% · Q4 5.1% · 4Q avg 34.2% · 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 0.0% · Q2 1.4% · 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 | 0.6% |
1.5%
0.9 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.8% |
22.4%
10.4 pts worse
|
19.8%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 27.9% · Q3 37.0% · Q4 31.5% · 4Q avg 32.8% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
3.7%
0.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 4.2% · Q4 4.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.2% |
76.4%
11.2 pts worse
|
81.7%
16.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.0% · Q2 70.5% · Q3 74.5% · Q4 54.0% · 4Q avg 65.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.8% |
1.5%
4.3 pts worse
|
1.6%
4.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.9% |
75.6%
9.7 pts worse
|
79.7%
13.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.9% |
Survey summary
Top issue: Administration (6 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Develop a communication plan.
Corrected 2023-12-29
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-12-29
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-12-29
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-12-29
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-12
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-12
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-07-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-21
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-07-26
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-08
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-08-08
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-08
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 2025-02-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-29
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-12-29
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-29
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-29
Health
Keep all essential equipment working safely.
Corrected 2023-12-29
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-12-29
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-12-29
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-12-29
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-12-29
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 2023-12-29
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-29
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-12-29
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 2023-12-29
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-12-29
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 2023-08-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-28
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-09-28
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-09-28
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 2022-09-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-28
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-28
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 2022-09-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-07-22
Health
Dispose of garbage and refuse properly.
Corrected 2021-07-22
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-07-22
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-07-22
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 2021-07-22
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-07-22
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 2021-07-22
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-07-22
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-22
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 2021-07-22
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2021-07-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-22
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-07-22
Penalties and ownership
Fine · fine $30,862
Fine
Fine · fine $3,529
Fine
Fine · fine $8,469
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
Windsor, CO
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
Greeley, CO
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Greeley, CO
2-star overall rating with 2-star inspections with $39,384 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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