Cycle 1
Health 2024-11-21 · Fire 2024-11-21
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Durango, CO
Cottonwood Rehabilitation And Healthcare Center
5-star overall rating with 4-star inspections with $22,152 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
450 Prospector Ave, Durango, CO
(970) 516-1404
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
40
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Centennial Healthcare
Operator or chain grouping
Approved since
2014-03-25
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 2 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
1.45
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.21
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.63
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.28
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,952
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0074
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.98
Baseline 18.09% · Performance 17.73% · Measure score 7.98 · Achievement 7.98 · Improvement 2.87
Healthcare-associated infections
6.40
Baseline 5.61% · Performance 5.92% · Measure score 6.40 · Achievement 6.40 · Improvement 0
Total nurse turnover
3.68
Performance 48.65% · Measure score 3.68 · Achievement 3.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.05
Baseline 4.50 hours · Performance 3.95 hours · Measure score 3.05 · Achievement 3.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.71% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 184 · Observed rate 6.52% · Lower 95% interval 6.86% |
| Discharge to community | 69.69% |
50.57%
19.1 pts better
|
Better than the National Rate · Eligible stays 182 · Observed rate 74.73% · Lower 95% interval 62.89% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 120 · Denominator 120 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 3 · Denominator 120 |
| Discharge self-care score | 77.66% |
53.69%
24 pts better
|
Numerator 73 · Denominator 94 |
| Discharge mobility score | 75.53% |
50.94%
24.6 pts better
|
Numerator 71 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 120 · Adjusted rate 3.15% |
| Healthcare-associated infections requiring hospitalization | 5.92% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 2.02% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 4.05% |
8.2%
4.1 pts worse
|
Numerator 3 · Denominator 74 |
| Staff flu vaccination coverage | 96.1% |
42%
54.1 pts better
|
Numerator 74 · Denominator 77 |
| Discharge function score | 79.79% |
56.45%
23.3 pts better
|
Numerator 75 · Denominator 94 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 34.92% |
25.2%
9.7 pts better
|
Numerator 22 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.4%
2.3 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.1% · Q3 9.5% · Q4 0.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.7% |
7.4%
17.3 pts worse
|
11.4%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 47.6% · Q3 25.0% · Q4 9.1% · 4Q avg 24.7% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.0%
2.4 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 10.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.1% |
11.2%
22.9 pts worse
|
19.6%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 30.0% · Q4 38.1% · 4Q avg 34.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
20.6%
7.6 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · 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 | 7.8% |
15.2%
7.4 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
14.6%
6.1 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 15.0% · Q4 0.0% · 4Q avg 8.5% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.5%
0.9 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
22.4%
2.8 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
3.7%
1.7 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
76.4%
22.4 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.0% · Q3 98.2% · Q4 99.1% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
12.8%
4.1 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 14.9% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.2% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
75.6%
21.5 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
20.3%
1.1 pts worse
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 18.4% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-12 · Fire 2023-07-12
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-04-07 · Fire 2022-04-07
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
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 2024-12-30
F · Potential for more than minimal harm
2024-11-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-11-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-11-21
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 2024-12-24
E · Potential for more than minimal harm
2024-11-21
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 2025-01-16
D · Potential for more than minimal harm
2024-11-21
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-31
E · Potential for more than minimal harm
2023-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-09
D · Potential for more than minimal harm
2022-04-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-05-19
D · Potential for more than minimal harm
2022-04-07
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-05-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-21
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-12-20
G · Actual harm
2023-07-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-10
G · Actual harm
2023-07-12
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 2023-08-10
E · Potential for more than minimal harm
2023-07-12
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-07-12
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 2023-08-10
G · Actual harm
2022-04-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-04-07
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 2022-04-08
Penalties and ownership
What sits behind the stars
$22,152
2023-07-12
Fine
Fine · fine $22,152
Fine
Ownership
Centennial Iii Colorado Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Gottlieb, Refoel
5% Or Greater Indirect Ownership Interest · Individual
Centennial Mn Tr I
5% Or Greater Indirect Ownership Interest · Organization
Centennial Ms Trust I
5% Or Greater Indirect Ownership Interest · Organization
Centennial Yf Trust I
5% Or Greater Indirect Ownership Interest · Organization
Emssah Non- Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Weintraub, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Bradley, Christine
Operational/Managerial Control · Individual
Capital Finance LLC
Operational/Managerial Control · Organization
Capital Finance LLC
5% Or Greater Security Interest · Organization
Gottlieb, Refoel
Operational/Managerial Control · Individual
Gotts Consulting Colorado LLC
Operational/Managerial Control · Organization
Turpen, Mark
Operational/Managerial Control · Individual
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#3
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