Grand River Health Care Center

Name: Grand River Health Care Center
Address: 701 E 5TH ST, Rifle, CO, 81650, US
Telephone: 9706251514

701 E 5th St, Rifle, CO 81650 · Garfield County · 57 certified beds · avg 53 residents/day · certified since Dec 1, 2003

2/5

Health inspection rating (on-site)

Serious findings on record

$22,171

Fines, last 3 years

5.74

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jan 30, 2026 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jan 30, 2026 (Deficient, Provider has date of correction)

All citations in the current public record (11)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jan 30, 2026	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 30, 2026	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
Jan 30, 2026	D · Potential for harm, one-off	The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost.
Jan 30, 2026	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Jan 30, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 8, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 8, 2024	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Feb 8, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 8, 2024	D · Potential for harm, one-off	The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Feb 8, 2024	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 8, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 5).

Year	Citations	Serious (G–L)	Worst severity that year
2024	6	0	E
2026	5	1	J ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $22,171.

Date	Type	Amount / length
Jan 30, 2026	Fine	$22,171

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Colorado avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.74	3.89	3.95	top 5% in Colorado; top 5% in the U.S.
Registered Nurse hours	1.35	0.86	0.69	top 8% in Colorado; top 7% in the U.S.
Weekend total nurse staffing	4.97	3.44	3.50	top 6% in Colorado; top 7% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.80	0.61	0.48	top 20% in Colorado; top 11% in the U.S.
Total nursing staff turnover (%)	40.0	47.1	45.8	top 30% in Colorado; top 36% in the U.S.
RN turnover (%)	53.3	44.6	42.9	bottom 31% in Colorado; bottom 31% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.85, RN 1.14, weekend 4.21. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 3/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Grand River Hospital District	Organization	5% or Greater Direct Ownership Interest	100%	01/01/1966
Coombs, James	Individual	Corporate Officer	NOT APPLICABLE	05/01/2006
Ellis, Todd	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/27/2023
Ellis, Todd	Individual	Trustee of the SNF	NOT APPLICABLE	02/27/2023
Mendizabal, Raquel	Individual	Managing Control - Governing Body	NOT APPLICABLE	06/01/2019
Mendizabal, Raquel	Individual	Trustee of the SNF	NOT APPLICABLE	06/01/2019
Paget, Chavien	Individual	W-2 Managing Employee	NOT APPLICABLE	11/01/2024
Paget, Chavien	Individual	ADP of the SNF	NOT APPLICABLE	12/12/2024
Rickstrew, Jay	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/27/2023
Rickstrew, Jay	Individual	Trustee of the SNF	NOT APPLICABLE	02/27/2023
Will, Perry	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/27/2023
Will, Perry	Individual	Trustee of the SNF	NOT APPLICABLE	02/27/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How often do you evaluate your nurse aides and what ongoing training do they receive?"
"Can I get a written copy of resident rights, house rules, and a full list of services and charges today?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Colorado State Veterans Nursing Home - Rifle	0.5 mi	Rifle, CO	★★☆☆☆	1/5	abuse

Compare this facility with the 1 closest →

All facilities in Rifle →

Facility data as of CMS processing date 2026-08-01. CCN 065381.

The Care File

Visit checklist — Grand River Health Care Center

701 E 5th St, Rifle, CO 81650 · 9706251514

Health inspection rating 2/5 · CMS overall 3/5· Fines (3y): $22,171

Most serious findings on record:

▲ Jan 30, 2026 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How often do you evaluate your nurse aides and what ongoing training do they receive?"
☐ "Can I get a written copy of resident rights, house rules, and a full list of services and charges today?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 065381 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)