Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- ColoradoAbove 57% of peers208 rated homes · average 3.1★
- Adams CountyAbove 77% of peers14 rated homes · average 2.9★
- United StatesAbove 61% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point3★+0.3 vs CO avg
- StaffingCan add or remove a star3★−0.1 vs CO avg
- Quality measuresCan add or remove a star5★+0.8 vs CO avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 49% of peersCO avg2.7★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 31% of peersCO avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 50% of peersCO avg4.2★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.01hrsAbove only 10% of peersCO avg3.73Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.57hrsAbove only 21% of peersCO avg0.83Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better30%Top 9%CO avg49%RN turnover19%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$19,988Above only 39% of peersCO avg$25,587Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthDec 2022 – Apr 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Apr 3, 2025Cycle 1worst E · no actual harm
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareD · isolatedCorrected May 2, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 2, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 2, 2025
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 2, 2025
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected May 2, 2025
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 2, 2025
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected May 2, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 2, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 2, 2025
Mar 11, 2024Cycle 2worst G · actual harm$19,988
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Apr 4, 2024
- F575Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.Resident RightsE · patternCorrected Apr 4, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 4, 2024
- F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 4, 2024
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Apr 4, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Apr 4, 2024
- F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareG · isolatedCorrected Apr 4, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Apr 4, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Apr 4, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 4, 2024
- F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected Apr 4, 2024
Apr 6, 2023Cycle 3worst E · no actual harm
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsE · patternCorrected Apr 25, 2023
- F572Give residents a notice of rights, rules, services and charges.Resident RightsD · isolatedCorrected Apr 25, 2023
- F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Apr 25, 2023
Feb 16, 2023Cycle 3worst F · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 17, 2023
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected Mar 17, 2023
Dec 5, 2022Cycle 3worst G · actual harm
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsD · isolatedCorrected Dec 26, 2022
- F584Honor 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.Resident RightsE · patternCorrected Dec 26, 2022
- F585Honor 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.Resident RightsE · patternCorrected Dec 26, 2022
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 26, 2022
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Dec 26, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Dec 26, 2022
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareE · patternCorrected Dec 26, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.01hrs
- Registered nursesRN hours only0.57hrs
- Licensed practical nursesLPN hours0.52hrs
- Nurse aidesCNA hours1.91hrs
- Weekend nursingAll staff on Saturdays and Sundays2.53hrs
- Colorado average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better30%Top 9%CO avg 49%
- RN turnoverRegistered nurses only19%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy160 certified beds · ~145 residents a day91%Above 75% of peersCO avg 79%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $19,988In fines
- 1Fine
- 0Payment denials
- $25,587CO avg in fines
Actions on record
- Mar 11, 2024Civil money penalty$19,988
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- The Ensign Group324 facilities in the chain3.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Christopher Horton
- Hugo Ramirez Sanchez
- Soon Burnam
- David Jorgensen
- Chad Keetch
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 065108 · 2501 E 104TH AVE, THORNTON, CO, 80233.
- Percentiles compare this facility with every rated nursing home in Colorado and Adams County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









