Irondale Post Acute
7150 Poplar St, Commerce City, CO 80022 · Adams County · 95 certified beds · avg 79 residents/day · certified since Feb 1, 1994
SFF Candidate
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Oct 9, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Nov 11, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Apr 30, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 28, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Feb 12, 2026 · F-0688
The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Why it matters: Without this care, residents can develop stiff, contracted joints and lose the ability to move on their own.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 13, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 20, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 12, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Dec 14, 2023 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 4, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 1, 2022 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 9, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (27)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 12, 2026 | ▲ G · Actual harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 8, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Oct 9, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 9, 2025 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Apr 30, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 20, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 14, 2023 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Dec 14, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Sep 13, 2023 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint |
| Sep 1, 2022 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 1, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 2 | 1 | G ▲ |
| 2023 | 10 | 1 | G ▲ |
| 2024 | 1 | 1 | G ▲ |
| 2025 | 4 | 2 | L ▲ |
| 2026 | 10 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
5 fines totaling $131,261, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Feb 12, 2026 | Fine | $50,400 |
| Oct 9, 2025 | Fine | $30,076 |
| Apr 30, 2025 | Fine | $17,345 |
| Nov 20, 2024 | Fine | $8,338 |
| Dec 14, 2023 | Fine | $25,102 |
| Dec 14, 2023 | Payment Denial | 32 days from Jan 13, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.99 | 3.89 | 3.95 | top 36% in Colorado; top 40% in the U.S. |
| Registered Nurse hours | 0.71 | 0.86 | 0.69 | bottom 39% in Colorado; top 35% in the U.S. |
| Weekend total nurse staffing | 3.55 | 3.44 | 3.50 | top 36% in Colorado; top 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.56 | 0.61 | 0.48 | top 45% in Colorado; top 26% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 47.1 | 45.8 | — |
| RN turnover (%) | 0.0 | 44.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.35, RN 0.60, weekend 2.98. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 08/14/2019 |
| Englade, Keith | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2020 |
| Englade, Keith | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2020 |
| Englade, Keith | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2020 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 08/14/2019 |
| Graham, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2020 |
| Horton, Christopher | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2020 |
| Horton, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2020 |
| Horton, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2020 |
| Jorgensen, David | Individual | Corporate Director | NOT APPLICABLE | 03/01/2020 |
| Kare Technologies LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2020 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/07/2025 |
| Prime Time Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2020 |
| Sato, Ami | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Ridgeview Post Acute | 1.3 mi | Commerce City, CO | ★★★★☆ | 3/5 | |
| City Scape Rehabilitation & Care Center LLC | 4.4 mi | Denver, CO | ★★☆☆☆ | 1/5 | abuse |
| Thornton Care Center | 4.8 mi | Thornton, CO | ★☆☆☆☆ | 1/5 | |
| Villas at Sunny Acres, the | 4.9 mi | Thornton, CO | ★★☆☆☆ | 2/5 | abuse |
| City Park Healthcare and Rehabilitation Center | 6.1 mi | Denver, CO | ★★★☆☆ | 2/5 | abuse |
| Denver North Care Center | 6.2 mi | Denver, CO | ★★★☆☆ | 3/5 | |
| Clear Creek Care Center | 6.4 mi | Westminster, CO | ★★★☆☆ | 2/5 | |
| Skylake Post Acute | 6.4 mi | Thornton, CO | ★☆☆☆☆ | 1/5 | |
| Malley Transitional Care Center | 6.5 mi | Northglenn, CO | ★★☆☆☆ | 2/5 | |
| Briarwood Health Care Center | 6.6 mi | Denver, CO | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 065318.