River Valley Rehabilitation and Healthcare Center
1335 6th St, Del Norte, CO 81132 · Rio Grande County · 60 certified beds · avg 57 residents/day · certified since Aug 16, 2017
Abuse citation flag (CMS)
Part of chain: CENTENNIAL HEALTHCARE (8 facilities, chain avg rating 2.4★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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)
▲ Actual harm, one-off · Jul 13, 2023 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 11, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (29)
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 |
|---|---|---|
| Apr 2, 2025 | F · Potential for harm, facility-wide | 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. · from a complaint |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive. |
| Dec 19, 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. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Dec 19, 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. |
| Dec 19, 2024 | 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. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Dec 19, 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. · from a complaint |
| Jul 13, 2023 | ▲ G · Actual 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. |
| Jul 13, 2023 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jul 13, 2023 | E · Potential for harm, repeated | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Jul 13, 2023 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Jul 13, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jul 13, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 13, 2023 | 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. |
| Jul 13, 2023 | E · Potential for harm, repeated | 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. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jan 24, 2020 | F · Potential for harm, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jan 24, 2020 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jan 24, 2020 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (14 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2020 | 3 | 0 | F |
| 2023 | 14 | 1 | G ▲ |
| 2024 | 11 | 0 | E |
| 2025 | 1 | 0 | F |
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)
No fines or payment denials in the published 3-year window.
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) | 2.31 | 3.89 | 3.95 | bottom 1% in Colorado; bottom 2% in the U.S. |
| Registered Nurse hours | 0.53 | 0.86 | 0.69 | bottom 18% in Colorado; bottom 42% in the U.S. |
| Weekend total nurse staffing | 2.08 | 3.44 | 3.50 | bottom 1% in Colorado; bottom 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.59 | 0.61 | 0.48 | top 40% in Colorado; top 24% in the U.S. |
| Total nursing staff turnover (%) | 46.8 | 47.1 | 45.8 | bottom 50% in Colorado; bottom 45% in the U.S. |
| RN turnover (%) | 12.5 | 44.6 | 42.9 | top 4% in Colorado; top 6% 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 2.79, RN 0.64, weekend 2.51. Staffing rating: 2/5.
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: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Centennial I TBD Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2022 |
| Centennial MN Tr I | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2025 |
| Bank Hapoalim B.M. | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 04/30/2025 |
| Bank Hapoalim B.M. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/30/2025 |
| Gottlieb, Refoel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2022 |
| Gottlieb, Refoel | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2022 |
| Gottlieb, Refoel | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2022 |
| Klippert, Crystal | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/17/2024 |
| Klippert, Crystal | Individual | ADP of the SNF | NOT APPLICABLE | 09/30/2025 |
| Walker, Kelsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Walker, Kelsey | Individual | ADP of the SNF | NOT APPLICABLE | 09/30/2025 |
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?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How do you make sure every shift actually follows each resident's care plan?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "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 |
|---|---|---|---|---|---|
| Rock Creek Rehabilitation and Healthcare Center | 14.3 mi | Monte Vista, CO | ★☆☆☆☆ | 2/5 | abuse |
| Colorado Veterans Community Living Ctr at Homelake | 15.4 mi | Monte Vista, CO | ★★★★★ | 5/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065424.