25 health deficiencies
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Grand Junction, CO
1-star overall rating with 1-star inspections with $58,386 in total fines with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2425 Teller Ave, Grand Junction, CO
(970) 243-3381
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
70
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1990-12-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.43
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
11,066
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.94
Performance 20.07% · Measure score 2.94 · Achievement 2.94 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.53
Performance 7.38% · Measure score 1.53 · Achievement 1.53 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.78
Baseline 77.61% · Performance 60.29% · Measure score 2.78 · Achievement 0.83 · Improvement 2.78
Adjusted total nurse staffing
0
Baseline 3.23 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.2% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 6.23% |
| Discharge to community | 46.67% |
50.57%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 40.48% · Lower 95% interval 35.06% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 2.33% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 43 |
| Discharge self-care score | 69.44% |
53.69%
15.8 pts better
|
Numerator 25 · Denominator 36 |
| Discharge mobility score | 47.22% |
50.94%
3.7 pts worse
|
Numerator 17 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 1 · Denominator 43 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 7.38% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 74 |
| Staff flu vaccination coverage | 28.97% |
42%
13 pts worse
|
Numerator 31 · Denominator 107 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 27 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
93.5%
0.6 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 95.0% · Q3 96.7% · Q4 94.8% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
94.7%
2.4 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.4%
2.5 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 8.3% · Q3 5.0% · Q4 5.2% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
7.4%
0.9 pts worse
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 5.2% · Q3 5.4% · Q4 9.1% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.0%
0.2 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.3% · Q3 8.3% · Q4 4.3% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
11.2%
0.8 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 10.9% · Q3 8.3% · Q4 8.3% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.0% |
20.6%
3.6 pts better
|
16.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 13.5% · Q3 21.6% · Q4 14.3% · 4Q avg 17.0% · 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 | 6.3% |
15.2%
8.9 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 3.9% · Q3 6.4% · Q4 3.3% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
14.6%
7.1 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 4.4% · Q3 8.5% · Q4 4.3% · 4Q avg 7.5% · 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 · 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 | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
22.4%
9.1 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 9.2% · Q3 10.4% · Q4 11.4% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
3.7%
3.8 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 5.7% · Q3 7.1% · Q4 4.9% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.2% |
76.4%
17.2 pts worse
|
81.7%
22.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.1% · Q2 59.2% · Q3 59.2% · Q4 50.0% · 4Q avg 59.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.4% |
12.8%
5.6 pts worse
|
12.0%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 18.2% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.0% · Q4 10.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.2% |
75.6%
10.4 pts worse
|
79.7%
14.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
20.3%
2.8 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 18.2% · Expected 24.8% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-12
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-12
Inspection history
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Not marked corrected
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-25
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-07-25
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-07-25
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-03-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-09
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-12
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-12
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-07-12
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-12
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-07-12
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-07-12
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-12
Health
Keep all essential equipment working safely.
Corrected 2024-07-12
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-07-12
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-07-12
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-07-12
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-12
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-12
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-12
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-07-12
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-07-12
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-07-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-12
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 2024-07-12
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 2024-07-12
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-07-12
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-07-12
Health
Post nurse staffing information every day.
Corrected 2024-07-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-09
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2020-03-09
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 2020-03-09
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-03-09
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-03-09
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 2019-01-15
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 2019-01-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-01-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-01-15
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-15
Penalties and ownership
Fine · fine $14,015
Fine
Fine · fine $13,625
Fine
Fine · fine $30,746
Fine
Payment Denial · denial start 2024-07-11 · 1 days
1 day denial
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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