Cycle 1
Health 2024-07-16 · Fire 2024-07-16
5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Commerce City, CO
Ridgeview Post Acute
3-star overall rating with 2-star inspections with abuse icon flag with 5 recent health deficiencies
5230 E 66th Way, Commerce City, CO
(303) 289-1848
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1990-10-01
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
0.64
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,048
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9944
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
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
7.54
Baseline 26.09% · Performance 32.88% · Measure score 7.54 · Achievement 7.54 · Improvement 0
Adjusted total nurse staffing
0.77
Baseline 3.44 hours · Performance 3.30 hours · Measure score 0.77 · Achievement 0.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 11.54% · Lower 95% interval 7.19% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 24 · Denominator 25 |
| Falls with major injury | 4% |
0.77%
3.2 pts worse
|
Numerator 1 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| 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 | 17.69% |
8.2%
9.5 pts better
|
Numerator 23 · Denominator 130 |
| Staff flu vaccination coverage | 90.85% |
42%
48.8 pts better
|
Numerator 149 · Denominator 164 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.7
1.3 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
93.5%
4.9 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.4% · 4Q avg 98.4% |
| 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 | 1.6% |
3.4%
1.8 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
7.4%
3.5 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.9% · Q3 2.5% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.0%
2.3 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.3% · Q3 14.0% · Q4 8.1% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.2% |
11.2%
7 pts better
|
19.6%
15.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.4% · Q3 3.4% · Q4 4.7% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.4% |
20.6%
6.8 pts worse
|
16.7%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 30.4% · Q3 24.6% · Q4 29.5% · 4Q avg 27.4% · 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 | 9.2% |
15.2%
6 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 3.5% · Q3 13.3% · Q4 9.9% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
14.6%
3.1 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 5.6% · Q3 25.9% · Q4 5.0% · 4Q avg 11.5% · 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 | 0.3% |
1.5%
1.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.1% |
22.4%
8.7 pts worse
|
19.8%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 32.2% · Q3 21.0% · Q4 34.2% · 4Q avg 31.1% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
3.7%
1 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.1% · Q3 1.5% · Q4 2.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.5% |
76.4%
2.9 pts worse
|
81.7%
8.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 90.0% · Q3 76.5% · Q4 38.8% · 4Q avg 73.5% |
| 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 · 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 | 76.2% |
75.6%
0.6 pts better
|
79.7%
3.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-17 · Fire 2023-02-17
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.
Cycle 3
Health 2022-01-18 · Fire 2022-01-18
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-16
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 2024-08-15
D · Potential for more than minimal harm
2024-07-16
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 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-16
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 2024-08-09
D · Potential for more than minimal harm
2024-07-16
F849 · Administration Deficiencies
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 2024-08-09
J · Immediate jeopardy
2023-02-17
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 2023-03-21
F · Potential for more than minimal harm
2023-02-17
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-03-21
L · Immediate jeopardy
2022-01-18
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-01-18
K · Immediate jeopardy
2022-01-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-16
F · Potential for more than minimal harm
2022-01-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-02-11
D · Potential for more than minimal harm
2022-01-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-02-11
Penalties and ownership
What sits behind the stars
Ownership
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Creason, Jonathan
Operational/Managerial Control · Individual
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Graham, Joseph
Corporate Officer · Individual
Horton, Christopher
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Prime Time Healthcare LLC
Operational/Managerial Control · Organization
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Irondale Post Acute
Commerce City, CO
1-star overall rating with 1-star inspections with Special Focus status with $97,055 in total fines with 13 recent health deficiencies
#2
City Scape Rehabilitation & Care Center LLC
Denver, CO
2-star overall rating with 1-star inspections with abuse icon flag with $80,637 in total fines with 16 recent health deficiencies with 4 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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