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

Certified beds

Average residents

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

Staffing

Hours and turnover

RN hours / resident day

0.57

Registered nurse staffing

LPN hours / resident day

0.42

Licensed practical nurse staffing

Aide hours / resident day

1.39

Nurse aide staffing

Weekend hours

2.01

Weekend nurse staffing

RN turnover

57%

Annual RN turnover

Total nurse turnover

38%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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

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