Cycle 1
Health 2024-12-19 · Fire 2024-12-19
12 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Del Norte, CO
River Valley Rehabilitation And Healthcare Center
2-star overall rating with 2-star inspections with abuse icon flag with $14,768 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1335 6th St, Del Norte, CO
(719) 657-1105
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 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
2017-08-16
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
0.65
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.07
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
2.59
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,251
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.07
Performance 18.62% · Measure score 6.07 · Achievement 6.07 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.80
Performance 6.40% · Measure score 4.80 · Achievement 4.80 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.24
Performance 58.62% · Measure score 1.24 · Achievement 1.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.32 hours · Performance 2.76 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.38% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 11.39% · Lower 95% interval 7.99% |
| Discharge to community | 42.94% |
50.57%
7.6 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 37.78% · Lower 95% interval 31.7% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.08% |
95.27%
0.8 pts better
|
Numerator 49 · Denominator 51 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 51 |
| Discharge self-care score | 25.58% |
53.69%
28.1 pts worse
|
Numerator 11 · Denominator 43 |
| Discharge mobility score | 39.53% |
50.94%
11.4 pts worse
|
Numerator 17 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 51 · Adjusted rate 2.17% |
| Healthcare-associated infections requiring hospitalization | 6.4% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 2.33% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 88 |
| Staff flu vaccination coverage | 98.45% |
42%
56.5 pts better
|
Numerator 127 · Denominator 129 |
| Discharge function score | 46.51% |
56.45%
9.9 pts worse
|
Numerator 20 · Denominator 43 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28% |
25.2%
2.8 pts better
|
Numerator 7 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.3
1.2 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 6.8 |
1.7
5.1 pts worse
|
1.8
5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 6.8 · Observed 6.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
93.5%
5.1 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 98.0% · Q4 98.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.4%
0.5 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.5% · Q3 0.0% · Q4 2.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.8% |
7.4%
43.4 pts worse
|
11.4%
39.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 58.8% · Q3 57.1% · Q4 56.5% · 4Q avg 50.8% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.0%
4 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.2% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
11.2%
1.1 pts worse
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 10.9% · Q3 6.1% · Q4 17.0% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
20.6%
2.6 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 21.4% · Q3 25.6% · Q4 25.0% · 4Q avg 23.2% · 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 | 4.9% |
15.2%
10.3 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.9% · Q3 3.2% · Q4 6.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
14.6%
8.8 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 9.6% · Q3 4.3% · Q4 4.7% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.8%
0.6 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 21.9% |
22.4%
0.5 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 25.9% · Q3 22.8% · Q4 21.4% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
3.7%
0.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.8% · Q3 0.0% · Q4 2.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
76.4%
23.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
12.8%
3.1 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 16.2% · Expected 11.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
20.3%
5 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 27.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-13 · Fire 2023-07-13
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-01-24 · Fire 2020-01-24
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-30
F · Potential for more than minimal harm
2024-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-30
F · Potential for more than minimal harm
2023-07-13
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-08-28
F · Potential for more than minimal harm
2023-07-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-08-28
F · Potential for more than minimal harm
2023-07-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-08-28
F · Potential for more than minimal harm
2020-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-28
F · Potential for more than minimal harm
2020-01-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-24
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 2020-02-28
D · Potential for more than minimal harm
2020-01-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-02
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 2025-04-29
E · Potential for more than minimal harm
2024-12-19
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 2025-01-30
E · Potential for more than minimal harm
2024-12-19
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2025-01-30
E · Potential for more than minimal harm
2024-12-19
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 2025-01-30
D · Potential for more than minimal harm
2024-12-19
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 2025-01-30
D · Potential for more than minimal harm
2024-12-19
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 2025-01-30
D · Potential for more than minimal harm
2024-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-30
D · Potential for more than minimal harm
2024-12-19
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-01-30
D · Potential for more than minimal harm
2024-12-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-30
D · Potential for more than minimal harm
2024-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-30
D · Potential for more than minimal harm
2024-12-19
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.
Corrected 2025-01-30
D · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-30
G · Actual harm
2023-07-13
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 2023-08-11
F · Potential for more than minimal harm
2023-07-13
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-07-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-07-13
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-07-13
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 2023-08-11
E · Potential for more than minimal harm
2023-07-13
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 2023-08-11
E · Potential for more than minimal harm
2023-07-13
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 2023-08-11
E · Potential for more than minimal harm
2023-07-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
F · Potential for more than minimal harm
2020-01-24
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 2020-02-26
D · Potential for more than minimal harm
2020-01-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-02-18
D · Potential for more than minimal harm
2020-01-24
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 2020-02-18
Penalties and ownership
What sits behind the stars
$14,768
2023-07-13
Fine
Fine · fine $14,768
Fine
Ownership
Centennial Iii Colorado Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bank Hapoalim B.m.
Operational/Managerial Control · Organization
Bank Hapoalim B.m.
5% Or Greater Mortgage Interest · Organization
Centennial I Tbd Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Centennial M Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Centennial Mn Tr I
5% Or Greater Indirect Ownership Interest · Organization
Centennial Ms Trust I
5% Or Greater Indirect Ownership Interest · Organization
Centennial Yf Trust I
5% Or Greater Indirect Ownership Interest · Organization
Emssah Non- Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Gottlieb, Refoel
5% Or Greater Indirect Ownership Interest · Individual
Gottlieb, Refoel
Operational/Managerial Control · Individual
Klippert, Crystal
Operational/Managerial Control · Individual
Walker, Kelsey
Operational/Managerial Control · Individual
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