Cycle 1
Health 2024-04-11 · Fire 2024-04-11
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Greeley, CO
Westlake Health And Rehabilitation Center
3-star overall rating with 3-star inspections with $14,069 in total fines with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
1637 29th Ave Pl, Greeley, CO
(970) 356-8181
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
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
1985-07-01
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
0.61
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.11
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.27
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
0.51
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,272
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
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
2.09
Performance 7.21% · Measure score 2.09 · Achievement 2.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 65.62% · Performance 83.53% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.28 hours · Performance 2.37 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 9.62% · Lower 95% interval 7.02% |
| Discharge to community | 46.18% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 41.86% · Lower 95% interval 34.86% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 36 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 56% |
53.69%
2.3 pts better
|
Numerator 14 · Denominator 25 |
| Discharge mobility score | 36% |
50.94%
14.9 pts worse
|
Numerator 9 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 2.74% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 40.49% |
42%
1.5 pts worse
|
Numerator 66 · Denominator 163 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 16 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.7 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
93.5%
5.7 pts worse
|
93.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 93.8% · Q3 82.2% · Q4 91.9% · 4Q avg 87.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.2% |
94.7%
17.5 pts worse
|
95.5%
18.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 77.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.6% · Q3 2.7% · Q4 1.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
7.4%
5.3 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.7% · Q3 1.6% · Q4 1.5% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.0%
0.2 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.7% · Q3 6.9% · Q4 3.2% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.9% |
11.2%
1.3 pts better
|
19.6%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 7.5% · Q3 10.0% · Q4 8.1% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.0% |
20.6%
2.4 pts worse
|
16.7%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 28.9% · Q3 23.4% · Q4 18.8% · 4Q avg 23.0% · 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 | 8.3% |
15.2%
6.9 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 16.2% · Q4 12.2% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
14.6%
5.3 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 10.6% · Q3 3.4% · Q4 9.8% · 4Q avg 9.3% · 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 | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
22.4%
7.8 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 37.4% · Q3 31.0% · Q4 29.0% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
3.7%
1.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.6% · Q3 2.6% · Q4 1.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
76.4%
4.6 pts better
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.5% · Q2 86.2% · Q3 84.0% · Q4 89.5% · 4Q avg 81.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.3% |
75.6%
0.3 pts worse
|
79.7%
4.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-15 · Fire 2022-12-15
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2021-09-02 · Fire 2021-09-02
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-04-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-04-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-04-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-02
F · Potential for more than minimal harm
2024-04-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-04-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-04-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-04-11
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 2024-07-01
D · Potential for more than minimal harm
2024-04-11
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-04-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-04-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-04-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-01
F · Potential for more than minimal harm
2022-12-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-26
F · Potential for more than minimal harm
2022-12-15
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-01-20
F · Potential for more than minimal harm
2022-12-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-12
F · Potential for more than minimal harm
2022-12-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-12
F · Potential for more than minimal harm
2021-09-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-28
F · Potential for more than minimal harm
2021-09-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-24
F · Potential for more than minimal harm
2021-09-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-10-18
F · Potential for more than minimal harm
2021-09-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-31
F · Potential for more than minimal harm
2021-09-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-31
D · Potential for more than minimal harm
2021-09-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-10-18
D · Potential for more than minimal harm
2021-09-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-11-01
D · Potential for more than minimal harm
2021-09-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-07
J · Immediate jeopardy
2025-04-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-21
F · Potential for more than minimal harm
2024-10-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
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 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
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 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-03
E · Potential for more than minimal harm
2022-12-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-27
Penalties and ownership
What sits behind the stars
$14,069
2025-04-07
Fine
Fine · fine $14,069
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
Conley, Calvin
Operational/Managerial Control · Individual
Fraser, Malcolm
Operational/Managerial Control · Individual
Graham, Joseph
Corporate Officer · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Nursa Inc
Operational/Managerial Control · Organization
Onshift Inc
Operational/Managerial Control · Organization
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Broadview Health And Rehabilitation Center
Greeley, CO
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Fairacres Manor, Inc.
Greeley, CO
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Center At Centerplace, LLC, The
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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