11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Trinidad, CO
2-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
409 Benedicta Ave, Trinidad, CO
(719) 846-9291
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
Beds
119
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Centennial Healthcare
Operator or chain grouping
Approved since
1977-10-26
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
RN hours / resident day
0.43
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.29
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
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
6,941
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
1.01
Baseline 6.63% · Performance 7.53% · Measure score 1.01 · Achievement 1.01 · Improvement 0
Total nurse turnover
7.08
Performance 34.72% · Measure score 7.08 · Achievement 7.08 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.29
Baseline 3.57 hours · Performance 3.44 hours · Measure score 1.29 · Achievement 1.29 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 6.22% |
| Discharge to community | 36.51% |
50.57%
14.1 pts worse
|
Worse than the National Rate · Eligible stays 31 · Observed rate 25.81% · Lower 95% interval 24.48% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.48% |
95.27%
4.8 pts worse
|
Numerator 19 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 14.29% |
2.29%
12 pts worse
|
Numerator 3 · Denominator 21 · Adjusted rate 12.12% |
| Healthcare-associated infections requiring hospitalization | 7.53% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 8.57% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 16.35% |
8.2%
8.2 pts better
|
Numerator 17 · Denominator 104 |
| Staff flu vaccination coverage | 91.26% |
42%
49.3 pts better
|
Numerator 94 · Denominator 103 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · 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 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.4 |
1.7
2.7 pts worse
|
1.8
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 3.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
93.5%
5.3 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 96.4% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.7%
4.2 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.1% |
3.4%
5.7 pts worse
|
3.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 13.4% · Q3 8.6% · Q4 6.0% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.9% |
7.4%
27.5 pts worse
|
11.4%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 49.4% · Q3 36.7% · Q4 33.8% · 4Q avg 34.9% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.0%
1.7 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 19.4% · Q4 3.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
11.2%
2 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 9.3% · Q3 6.7% · Q4 6.4% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
20.6%
3.9 pts better
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 16.9% · Q3 16.7% · Q4 17.9% · 4Q avg 16.7% · 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 | 4.7% |
15.2%
10.5 pts better
|
16.3%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.4% · Q3 0.0% · Q4 7.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
14.6%
8.9 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.8% · Q3 1.4% · Q4 9.3% · 4Q avg 5.7% · 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 | 0.0% |
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 | 13.9% |
22.4%
8.5 pts better
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 5.9% · Q3 19.9% · Q4 18.1% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
3.7%
0.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.7% · Q3 2.8% · Q4 1.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.3% |
76.4%
3.9 pts better
|
81.7%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 96.6% · Q3 82.9% · Q4 64.4% · 4Q avg 80.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
12.8%
2.8 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 8.7% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.8% |
75.6%
7.2 pts better
|
79.7%
3.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
20.3%
0.8 pts worse
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 17.4% · Expected 19.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Establish methods for sharing information.
Corrected 2024-06-21
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2020-03-01
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-29
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-06
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-06-24
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-06-25
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-07
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-20
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-06-20
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 2024-06-26
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 2024-07-02
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2020-03-06
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-03-01
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-03-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-02
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2020-03-02
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2020-03-02
Health
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Corrected 2020-02-05
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2020-03-02
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2020-03-02
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-03-01
Health
Provide activities to meet all resident's needs.
Corrected 2020-03-01
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 2020-03-02
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2020-03-02
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-02
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-02
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2020-03-15
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 2020-03-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-03-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-01
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 2020-03-15
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 2019-03-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-03-08
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2019-03-11
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-03-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-03-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-02-26
Health
Provide activities to meet all resident's needs.
Corrected 2019-03-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-03-08
Penalties and ownership
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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