Grand Junction, CO

Eagle Ridge Post Acute

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

Compare this facility

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

Facility snapshot

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

Hours and turnover

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

Value-based purchasing

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

How the VBP score is built

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

Medicare quality reporting measures

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

Resident outcomes and process scores

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

Recent inspection cycles

Cycle 1 Health 2024-06-12 · Fire 2024-06-12

25 health deficiencies

Top issue: Resident Rights (5 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2020-02-13 · Fire 2020-02-13

13 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2018-12-13 · Fire 2018-12-13

6 health deficiencies

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 citations

F · Potential for more than minimal harm 2024-06-12

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-06-12

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-07-12

Inspection history

Recent health citations

G · Actual harm 2025-12-09

F806 · Nutrition and Dietary Deficiencies

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

D · Potential for more than minimal harm 2025-07-01

F580 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2025-07-01

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

D · Potential for more than minimal harm 2025-07-01

F627 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2025-07-01

F742 · Quality of Life and Care Deficiencies

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

E · Potential for more than minimal harm 2025-02-11

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-03-05

D · Potential for more than minimal harm 2024-08-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-09-09

D · Potential for more than minimal harm 2024-08-20

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-09-09

G · Actual harm 2024-06-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-06-12

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-06-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-06-12

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 2024-07-12

E · Potential for more than minimal harm 2024-06-12

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-06-12

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-06-12

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-06-12

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-06-12

F812 · Nutrition and Dietary Deficiencies

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

E · Potential for more than minimal harm 2024-06-12

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-06-12

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

E · Potential for more than minimal harm 2024-06-12

F947 · Nursing and Physician Services Deficiencies

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

D · Potential for more than minimal harm 2024-06-12

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-06-12

F580 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2024-06-12

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-06-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-06-12

F661 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2024-06-12

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-06-12

F688 · Quality of Life and Care Deficiencies

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

D · Potential for more than minimal harm 2024-06-12

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 2024-07-12

D · Potential for more than minimal harm 2024-06-12

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 2024-07-12

D · Potential for more than minimal harm 2024-06-12

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 2024-07-12

D · Potential for more than minimal harm 2024-06-12

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-07-12

D · Potential for more than minimal harm 2024-06-12

F849 · Administration Deficiencies

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

C · Minimal harm 2024-06-12

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-07-12

D · Potential for more than minimal harm 2023-11-17

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 2023-12-11

G · Actual harm 2020-02-13

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2020-03-09

F · Potential for more than minimal harm 2020-02-13

F725 · Nursing and Physician Services Deficiencies

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

E · Potential for more than minimal harm 2020-02-13

F584 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2020-02-13

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 2020-03-09

D · Potential for more than minimal harm 2020-02-13

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2020-03-09

E · Potential for more than minimal harm 2018-12-13

F584 · Resident Rights Deficiencies

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

E · Potential for more than minimal harm 2018-12-13

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 2019-01-15

D · Potential for more than minimal harm 2018-12-13

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 2019-01-15

D · Potential for more than minimal harm 2018-12-13

F842 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2018-12-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-01-15

Penalties and ownership

What sits behind the stars

$14,015 2025-12-09

Fine

Fine · fine $14,015

Fine

$13,625 2025-07-01

Fine

Fine · fine $13,625

Fine

$30,746 2024-06-12

Fine

Fine · fine $30,746

Fine

$0 2024-06-12

Payment Denial

Payment Denial · denial start 2024-07-11 · 1 days

1 day denial

Ownership

Centennial Master Tenant, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 10 facilities 2022-10-11
Apt, Frederick

Corporate Officer · Individual

0% 252 facilities 2024-01-01
Hancock, Mark

5% Or Greater Indirect Ownership Interest · Individual

0% 253 facilities 2024-04-15
Hancock, Mark

Corporate Officer · Individual

0% 253 facilities 2024-01-01
Jergensen, Joshua

Corporate Officer · Individual

0% 237 facilities 2024-01-01
Mitchell, John

Corporate Officer · Individual

0% 254 facilities 2024-01-01
Mohler, Amy

Contracted Managing Employee · Individual

0% 2 facilities 2014-01-06
Murray, Jason

5% Or Greater Indirect Ownership Interest · Individual

0% 250 facilities 2024-04-15
Pacs Group, Inc.

5% Or Greater Indirect Ownership Interest · Organization

0% 239 facilities 2023-06-30
Pacs Holdings, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 238 facilities 2023-06-30
Perkes, Blair

W-2 Managing Employee · Individual

0% 2 facilities 2023-04-24
Providence Group Nh, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 168 facilities 2023-06-30

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#3

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