Pagosa Springs, CO

Pine Ridge Rehabilitation And Healthcare Center

5-star overall rating with 4-star inspections with $3,145 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

119 Bastille Dr, Pagosa Springs, CO

(970) 731-4330

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

52

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Centennial Healthcare

Operator or chain grouping

Approved since

1998-01-16

CMS approved date

Coverage

Medicare + Medicaid

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

0.57

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.42

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

1.39

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

2.39

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.00

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.01

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.41

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.57

CMS adjusted RN staffing hours

Adjusted total hours

2.38

CMS adjusted total nurse staffing hours

Case-mix index

1.37

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

38%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,072

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.09

Composite VBP score used to determine payment impact.

Payment multiplier

0.9881

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.74

Performance 19.23% · Measure score 4.74 · Achievement 4.74 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

3.04

Performance 6.93% · Measure score 3.04 · Achievement 3.04 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

5.2

Performance 42.42% · Measure score 5.2 · Achievement 5.2 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.66

Baseline 3.49 hours · Performance 3.26 hours · Measure score 0.66 · Achievement 0.66 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.05%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 7.55%
Discharge to community	59.77%	50.57% 9.2 pts better	No Different than the National Rate · Eligible stays 60 · Observed rate 66.67% · Lower 95% interval 48.67%
Medicare spending per beneficiary	0.6	1.02 0.4 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 23 · Denominator 23
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 23
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 23 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.93%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 4.22%
Staff COVID-19 vaccination coverage	1.45%	8.2% 6.7 pts worse	Numerator 1 · Denominator 69
Staff flu vaccination coverage	94.29%	42% 52.3 pts better	Numerator 66 · Denominator 70
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
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	0.8	1.3 0.5 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.4	1.7 0.7 pts worse	1.8 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.8 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.3%	93.5% 4.8 pts better	93.4% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 97.8% · Q4 97.9% · 4Q avg 98.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.6%	94.7% 0.9 pts better	95.5% 0.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6%
Percentage of long-stay residents experiencing one or more falls with major injury	7.3%	3.4% 3.9 pts worse	3.3% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.8% · Q3 11.1% · Q4 4.3% · 4Q avg 7.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	35.9%	7.4% 28.5 pts worse	11.4% 24.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 58.1% · Q3 22.5% · Q4 30.4% · 4Q avg 35.9%
Percentage of long-stay residents who lose too much weight	0.6%	5.0% 4.4 pts better	5.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.3%	11.2% 3.1 pts worse	19.6% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 14.3% · Q3 14.0% · Q4 11.9% · 4Q avg 14.3%
Percentage of long-stay residents who received an antipsychotic medication	23.9%	20.6% 3.3 pts worse	16.7% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 24.2% · Q3 27.8% · Q4 23.5% · 4Q avg 23.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.6%	0.1% 0.5 pts worse	0.1% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.6%
Percentage of long-stay residents whose ability to walk independently worsened	5.0%	15.2% 10.2 pts better	16.3% 11.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.1% · Q3 6.2% · Q4 3.4% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.8%	14.6% 7.8 pts better	14.9% 8.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.9% · Q3 9.8% · Q4 5.0% · 4Q avg 6.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.2%	0.8% 0.4 pts worse	1.0% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.9% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	1.5% 0.9 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	12.0%	22.4% 10.4 pts better	19.8% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 8.3% · Q3 19.0% · Q4 10.4% · 4Q avg 12.0%
Percentage of long-stay residents with pressure ulcers	0.8%	3.7% 2.9 pts better	5.1% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.7%	76.4% 13.3 pts better	81.7% 8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 84.4% · Q3 88.9% · Q4 91.3% · 4Q avg 89.7%
Percentage of short-stay residents who had an outpatient emergency department visit	28.8%	12.8% 16 pts worse	12.0% 16.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 25.0% · Expected 9.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	65.6%	75.6% 10 pts worse	79.7% 14.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 65.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	12.2%	20.3% 8.1 pts better	23.9% 11.7 pts better	Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 10.0% · Expected 19.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-01-10 · Fire 2024-01-10

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2022-09-15 · Fire 2022-09-15

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2021-06-10 · Fire 2021-06-10

4 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-01-10

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-10

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-02-05

F · Potential for more than minimal harm 2022-09-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-03

E · Potential for more than minimal harm 2022-09-15

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2022-10-11

D · Potential for more than minimal harm 2021-06-10

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2021-07-12

D · Potential for more than minimal harm 2021-06-10

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2021-07-12

D · Potential for more than minimal harm 2021-06-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-07-25

D · Potential for more than minimal harm 2021-06-10

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2021-07-25

D · Potential for more than minimal harm 2021-06-10

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2021-07-25

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-01-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-02-02

E · Potential for more than minimal harm 2024-01-10

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 2024-02-02

D · Potential for more than minimal harm 2024-01-10

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 2024-02-02

D · Potential for more than minimal harm 2024-01-10

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 2024-02-02

J · Immediate jeopardy 2022-09-15

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 2022-04-05

F · Potential for more than minimal harm 2022-09-15

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 2022-10-06

F · Potential for more than minimal harm 2022-09-15

F867 · Administration Deficiencies

Health

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

Corrected 2022-10-05

E · Potential for more than minimal harm 2022-09-15

F565 · Resident Rights Deficiencies

Health

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

Corrected 2022-10-05

E · Potential for more than minimal harm 2022-09-15

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 2022-10-06

E · Potential for more than minimal harm 2022-09-15

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2022-10-05

E · Potential for more than minimal harm 2022-09-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-10-14

D · Potential for more than minimal harm 2022-09-15

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-10-06

D · Potential for more than minimal harm 2022-09-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-10-06

D · Potential for more than minimal harm 2022-09-15

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 2022-10-05

G · Actual harm 2021-06-10

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 2021-07-02

F · Potential for more than minimal harm 2021-06-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-07-02

E · Potential for more than minimal harm 2021-06-10

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2021-07-02

D · Potential for more than minimal harm 2021-06-10

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 2021-07-02

Penalties and ownership

What sits behind the stars

$3,145 2023-07-17

Fine

Fine · fine $3,145

Fine

Ownership

Centennial Iii Colorado Holdco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 6 facilities 2022-09-01

Capital Finance LLC

Operational/Managerial Control · Organization

0% 32 facilities 2022-09-01

Capital Finance LLC

5% Or Greater Security Interest · Organization

0% 32 facilities 2022-09-01

Centennial I Tbd Holdco LLC