21 health deficiencies
Top issue: Resident Rights (10 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Grand Junction, CO
1-star overall rating with 2-star inspections with abuse icon flag with $37,680 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2845 N 15th St, Grand Junction, CO
(970) 245-0022
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
130
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-09-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
4,462
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9928
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.22
Performance 19.47% · Measure score 4.22 · Achievement 4.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.44
Baseline 5.58% · Performance 6.21% · Measure score 5.44 · Achievement 5.44 · Improvement 0
Total nurse turnover
1.33
Baseline 50.50% · Performance 58.26% · Measure score 1.33 · Achievement 1.33 · Improvement 0
Adjusted total nurse staffing
4.96
Baseline 4.88 hours · Performance 4.49 hours · Measure score 4.96 · Achievement 4.96 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 5.5% · Lower 95% interval 6.92% |
| Discharge to community | 54.99% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 57.65% · Lower 95% interval 45.46% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 89 · Denominator 89 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 89 |
| Discharge self-care score | 57.53% |
53.69%
3.8 pts better
|
Numerator 42 · Denominator 73 |
| Discharge mobility score | 65.75% |
50.94%
14.8 pts better
|
Numerator 48 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 2.25% |
2.29%
About the same
|
Numerator 2 · Denominator 89 · Adjusted rate 3.12% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 3.8% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 2.94% |
8.2%
5.3 pts worse
|
Numerator 6 · Denominator 204 |
| Staff flu vaccination coverage | 87.92% |
42%
45.9 pts better
|
Numerator 233 · Denominator 265 |
| Discharge function score | 69.86% |
56.45%
13.4 pts better
|
Numerator 51 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 9.76% |
25.2%
15.4 pts worse
|
Numerator 4 · Denominator 41 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
93.5%
3.2 pts worse
|
93.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.5% · Q2 91.6% · Q3 92.6% · Q4 93.9% · 4Q avg 90.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.8% |
94.7%
11.9 pts worse
|
95.5%
12.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| 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 3.5% · Q2 7.2% · Q3 6.2% · Q4 6.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
7.4%
4.8 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 9.4% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.0%
2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.7% · Q3 1.8% · Q4 4.9% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.1% |
11.2%
4.1 pts better
|
19.6%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.8% · Q3 8.6% · Q4 8.2% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
20.6%
6.8 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.8% · Q3 14.0% · Q4 13.5% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.1%
0.2 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 47.5% |
15.2%
32.3 pts worse
|
16.3%
31.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.8% · 4Q avg 47.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.1% |
14.6%
16.5 pts worse
|
14.9%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.2% · Q2 32.7% · Q3 26.8% · Q4 17.2% · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.3% |
0.8%
5.5 pts worse
|
1.0%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.7% · Q3 5.9% · Q4 7.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.6% |
1.5%
3.1 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.9% · Q3 2.5% · Q4 6.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.1% |
22.4%
11.7 pts worse
|
19.8%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.4% · Q2 39.4% · Q3 27.5% · Q4 30.0% · 4Q avg 34.1% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
3.7%
0.5 pts worse
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.7% · Q3 5.4% · Q4 5.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.8% |
76.4%
2.4 pts better
|
81.7%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.5% · Q2 86.0% · Q3 72.2% · Q4 76.6% · 4Q avg 78.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
12.8%
5.9 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 17.2% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.9% |
75.6%
8.7 pts worse
|
79.7%
12.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
20.3%
2.4 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 20.7% · Expected 21.7% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (10 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-30
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 2024-05-30
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-30
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-30
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-20
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-20
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-02-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-10-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-10-11
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-10-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-10-11
Fire Safety
Use approved construction type or materials.
Corrected 2021-10-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-10-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-11
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-10-11
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-10-11
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-10-11
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-19
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-15
Health
Honor 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.
Corrected 2025-12-15
Health
Provide or obtain dental services for each resident.
Corrected 2025-12-15
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-14
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-14
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-05-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-05
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-05
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-05
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 2024-05-05
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-05-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-05
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-05-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-05
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-05
Health
Provide or obtain dental services for each resident.
Corrected 2024-05-05
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-05-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-01
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-13
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-09-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-09-20
Health
Respond appropriately to all alleged violations.
Corrected 2021-09-20
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 2021-09-20
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-09-20
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-09-20
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2021-09-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-09-20
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-09-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-09-20
Penalties and ownership
Fine · fine $26,500
Fine
Fine · fine $11,180
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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