Cycle 1
Health 2025-06-26 · Fire 2025-06-26
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fort Collins, CO
Rehabilitation And Nursing Center Of The Rockies
3-star overall rating with 2-star inspections with $21,327 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1020 Patton St, Fort Collins, CO
(970) 484-7981
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
106
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1984-09-01
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
0.49
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.17
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
1.11
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,438
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.32
Baseline 18.64% · Performance 20.36% · Measure score 2.32 · Achievement 2.32 · Improvement 0
Healthcare-associated infections
4.93
Baseline 5.64% · Performance 6.36% · Measure score 4.93 · Achievement 4.93 · Improvement 0
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.3
Baseline 3.27 hours · Performance 3.45 hours · Measure score 1.3 · Achievement 1.3 · Improvement 0.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 10.23% · Lower 95% interval 7.06% |
| Discharge to community | 56.89% |
50.57%
6.3 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 50% · Lower 95% interval 46.05% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.91% |
95.27%
3.6 pts better
|
Numerator 91 · Denominator 92 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 92 |
| Discharge self-care score | 67.19% |
53.69%
13.5 pts better
|
Numerator 43 · Denominator 64 |
| Discharge mobility score | 64.06% |
50.94%
13.1 pts better
|
Numerator 41 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 1.34% |
| Healthcare-associated infections requiring hospitalization | 6.36% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 5.33% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 129 |
| Staff flu vaccination coverage | 94.81% |
42%
52.8 pts better
|
Numerator 146 · Denominator 154 |
| Discharge function score | 73.44% |
56.45%
17 pts better
|
Numerator 47 · Denominator 64 |
| Transfer of health information to provider | 92.68% |
95.95%
3.3 pts worse
|
Numerator 38 · Denominator 41 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 24 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 39.62% |
25.2%
14.4 pts better
|
Numerator 21 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
93.5%
4.7 pts worse
|
93.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 93.2% · Q3 91.7% · Q4 80.3% · 4Q avg 88.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.7%
1.5 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| 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 0.0% · Q2 2.7% · Q3 2.8% · Q4 4.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.2% |
7.4%
3.8 pts worse
|
11.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 12.3% · Q3 10.4% · Q4 4.6% · 4Q avg 11.2% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.0%
1.3 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 10.4% · Q3 2.9% · Q4 7.5% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
11.2%
4.2 pts worse
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 20.0% · Q3 13.2% · Q4 14.7% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.8% |
20.6%
3.2 pts worse
|
16.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 28.1% · Q3 24.5% · Q4 16.9% · 4Q avg 23.8% · 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 | 14.8% |
15.2%
0.4 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 19.7% · Q3 11.6% · Q4 19.1% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
14.6%
1.4 pts worse
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 18.2% · Q3 7.7% · Q4 6.2% · 4Q avg 16.0% · 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 1.7% · Q2 0.0% · 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 | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
22.4%
6.7 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 28.6% · Q3 29.9% · Q4 36.3% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
3.7%
2.3 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.2% |
76.4%
1.2 pts worse
|
81.7%
6.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 77.7% · Q3 74.0% · Q4 71.1% · 4Q avg 75.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
12.8%
5.8 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 8.0% · Expected 12.8% · 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 | 71.3% |
75.6%
4.3 pts worse
|
79.7%
8.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
20.3%
7.6 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 32.0% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-12 · Fire 2023-12-12
6 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-11-21 · Fire 2019-11-21
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-31
F · Potential for more than minimal harm
2025-06-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-01
F · Potential for more than minimal harm
2023-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-09
D · Potential for more than minimal harm
2023-12-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-09
D · Potential for more than minimal harm
2023-12-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-09
D · Potential for more than minimal harm
2019-11-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-30
D · Potential for more than minimal harm
2019-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-06
D · Potential for more than minimal harm
2019-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-30
D · Potential for more than minimal harm
2019-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-30
D · Potential for more than minimal harm
2019-11-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-12-30
D · Potential for more than minimal harm
2019-11-21
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2019-12-30
D · Potential for more than minimal harm
2019-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-09-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-30
J · Immediate jeopardy
2025-06-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-20
G · Actual harm
2025-06-26
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 2025-07-20
E · Potential for more than minimal harm
2025-06-26
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-07-20
D · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-20
E · Potential for more than minimal harm
2024-10-23
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 2024-11-21
D · Potential for more than minimal harm
2024-10-23
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 2024-11-21
D · Potential for more than minimal harm
2024-05-01
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 2024-05-29
D · Potential for more than minimal harm
2024-05-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-29
D · Potential for more than minimal harm
2023-12-12
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 2024-01-10
D · Potential for more than minimal harm
2023-12-12
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 2024-01-26
D · Potential for more than minimal harm
2019-11-21
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 2019-12-16
D · Potential for more than minimal harm
2019-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-12-16
Penalties and ownership
What sits behind the stars
$21,327
2025-06-26
Fine
Fine · fine $21,327
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 Director · Individual
Burnam, Soon
Corporate Officer · Individual
Graham, Joseph
Corporate Officer · Individual
Jorgensen, David
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Truax, Todd
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Poudre Canyon Rehabilitation And Nursing, LLC
Fort Collins, CO
2-star overall rating with 1-star inspections with abuse icon flag with $45,688 in total fines with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Storybrook Care & Rehabilitation
Fort Collins, CO
2-star overall rating with 1-star inspections with $98,959 in total fines with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Creekside Village Rehabilitation And Nursing LLC
Fort Collins, CO
1-star overall rating with 1-star inspections with abuse icon flag with $28,042 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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