Cycle 1
Health 2024-06-27 · Fire 2024-06-27
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Loveland, CO
Riverbend Health And Rehabilitation Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
821 Duffield Ct, Loveland, CO
(970) 669-0345
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
100
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1982-07-01
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
0.70
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
1.94
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.41
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
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,330
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.21
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
0.68
Baseline 20.31% · Performance 21.12% · Measure score 0.68 · Achievement 0.68 · Improvement 0
Healthcare-associated infections
5.46
Baseline 7.84% · Performance 6.20% · Measure score 5.46 · Achievement 5.46 · Improvement 5.27
Total nurse turnover
0.74
Baseline 42.62% · Performance 60.66% · Measure score 0.74 · Achievement 0.74 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 6.07% |
| Discharge to community | 51.77% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 44.44% · Lower 95% interval 38.69% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.35% |
95.27%
0.1 pts better
|
Numerator 41 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 65.63% |
53.69%
11.9 pts better
|
Numerator 21 · Denominator 32 |
| Discharge mobility score | 53.13% |
50.94%
2.2 pts better
|
Numerator 17 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 43 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.2% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 2.78% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 70.59% |
42%
28.6 pts better
|
Numerator 96 · Denominator 136 |
| Discharge function score | 71.88% |
56.45%
15.4 pts better
|
Numerator 23 · Denominator 32 |
| 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 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24.14% |
25.2%
1.1 pts worse
|
Numerator 7 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
93.5%
3.6 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.6% · Q3 95.4% · Q4 97.1% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
94.7%
1.4 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 1.5% · Q4 4.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.5% |
7.4%
4.1 pts worse
|
11.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.5% · Q3 11.1% · Q4 14.9% · 4Q avg 11.5% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.0%
2.9 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 1.6% · Q3 1.8% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
11.2%
6.9 pts worse
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.0% · Q3 15.8% · Q4 13.3% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 39.1% |
20.6%
18.5 pts worse
|
16.7%
22.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.5% · Q2 46.8% · Q3 33.3% · Q4 31.5% · 4Q avg 39.1% · 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 | 26.4% |
15.2%
11.2 pts worse
|
16.3%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 34.6% · Q3 40.1% · Q4 6.8% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
14.6%
4 pts worse
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 33.3% · Q3 20.4% · Q4 5.3% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.8%
0.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 21.5% |
22.4%
0.9 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 27.8% · Q3 16.0% · Q4 26.2% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
3.7%
1.3 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.1% · Q3 3.5% · Q4 1.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.2% |
76.4%
18.2 pts worse
|
81.7%
23.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.1% · Q2 52.0% · Q3 52.9% · Q4 53.1% · 4Q avg 58.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.4% |
12.8%
9.6 pts worse
|
12.0%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 22.5% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.0% · Q3 2.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
75.6%
7.7 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.1% |
20.3%
8.2 pts better
|
23.9%
11.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 12.5% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-09 · Fire 2023-02-09
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-11-03 · Fire 2021-11-03
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-21
F · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-06-27
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-06-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-06-27
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-30
D · Potential for more than minimal harm
2024-06-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-06-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-08-27
F · Potential for more than minimal harm
2023-02-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-03
F · Potential for more than minimal harm
2023-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-16
F · Potential for more than minimal harm
2023-02-09
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-03-20
F · Potential for more than minimal harm
2021-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-21
F · Potential for more than minimal harm
2021-11-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-12-02
D · Potential for more than minimal harm
2021-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-11-03
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 2021-12-02
D · Potential for more than minimal harm
2021-11-03
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-12-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-06-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-27
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 2024-07-22
D · Potential for more than minimal harm
2024-06-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-22
F · Potential for more than minimal harm
2023-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-11
E · Potential for more than minimal harm
2023-02-09
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 2023-03-11
E · Potential for more than minimal harm
2023-02-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-11
E · Potential for more than minimal harm
2023-02-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-11
D · Potential for more than minimal harm
2023-02-09
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 2023-03-11
D · Potential for more than minimal harm
2023-02-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-11
D · Potential for more than minimal harm
2023-02-09
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-03-11
G · Actual harm
2021-11-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-12-03
G · Actual harm
2021-11-03
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 2021-12-03
F · Potential for more than minimal harm
2021-11-03
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-11-03
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 2021-12-03
E · Potential for more than minimal harm
2021-11-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-11-03
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-11-03
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 2021-12-03
E · Potential for more than minimal harm
2021-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-11-03
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 2021-12-03
D · Potential for more than minimal harm
2021-11-03
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 2021-12-03
D · Potential for more than minimal harm
2021-11-03
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 2021-12-03
Penalties and ownership
What sits behind the stars
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
Deckman, Courtney
Operational/Managerial Control · Individual
Graham, Joseph
Corporate Officer · Individual
Jorgensen, David
Corporate Director · Individual
Jorgensen, David
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
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4-star overall rating with 4-star inspections with $4,233 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
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5-star overall rating with 4-star inspections with $7,544 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
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