Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colorado State Veterans Nursing Home - Rifle during CMS and state inspections, most recent first.
The facility failed to maintain a safe environment, as evidenced by a resident found stuck between a bed and a transfer pole without prior safety assessment. This incident, along with the lack of safety risk assessments for 17 other residents with transfer poles, highlighted significant deficiencies. Additionally, the facility did not prevent falls or update care plans for several residents, and allowed a resident to smoke with an oxygen cannula, posing safety risks. Staff interviews revealed inadequate training and unclear procedures regarding transfer pole assessments.
A resident with multiple health issues, including diabetes and neuropathy, developed an unstageable pressure ulcer due to the facility's failure to ensure consistent use of offloading boots and address the resident's concerns about the boots' discomfort. The resident's refusals to wear the boots were not documented or care planned, leading to the worsening of her condition. Staff interviews revealed a lack of documentation and care planning for the resident's refusal to wear the boots, and facility records did not reflect the active order for heel protection.
The facility's QAPI program failed to identify and address multiple quality of care concerns, including safety risk assessments for transfer poles, fall prevention, and smoking hazards. The committee did not effectively document or analyze the causes of falls and did not review several critical issues such as water management, physical abuse protection, and appropriate food textures. The NHA and DON acknowledged the shortcomings in the QAPI process, which led to immediate jeopardy and potential harm to residents.
The facility failed to implement an effective water management plan to prevent Legionella, as recommended by CDC guidelines. The facility did not document weekly flushing of dead legs and low-flow piping runs, and staff interviews revealed inconsistencies in understanding and executing the plan. The DOM and NHA believed bi-weekly flushing was sufficient, while the IP and DON thought weekly flushing was necessary, leading to a deficiency in the infection control program.
The facility failed to maintain consistent temperature logs for medication and vaccine refrigerators, with records showing significant gaps in documentation. Staff interviews confirmed that temperatures should be logged daily, but many days were missing, potentially affecting medication safety.
The facility failed to protect residents from abuse, with incidents involving a CNA physically restraining a resident and two residents engaging in a physical altercation. Investigations revealed inadequate staff training and documentation, contributing to the deficiencies. The facility did not substantiate abuse in both cases due to lack of consistent injuries and fear.
A resident with paraplegia and other health issues did not receive bathing assistance per her preference, receiving only one bed bath since admission. Despite being cognitively intact and expressing a desire for two baths per week, the facility's documentation was inconsistent, and the resident's preferences were not properly recorded. The Director of Nursing acknowledged the deficiency in meeting the resident's bathing needs.
The facility failed to provide food in the correct form for two residents prescribed a mechanically altered diet. Both residents, diagnosed with dysphagia, were served regular textured Salisbury steak and dinner rolls instead of the required ground meat and pureed or gelled bread. Staff interviews revealed a lack of awareness regarding dietary requirements, and the facility had not implemented the IDDSI program.
The facility used blood pressure cuffs not rated for medical use, as observed with an LPN and an RN using wrist-type cuffs on residents. The DON confirmed the lack of verification for the cuffs' medical rating, and staff interviews revealed unawareness of the devices' suitability for medical use.
A resident in an LTC facility received an incorrect dose of morphine sulfate due to a nurse's failure to verify the medication concentration with the physician's order. The nurse administered 3.75 ml of a 20 mg/1 ml concentration instead of the prescribed 15 mg, leading to an overdose. The resident, who was over 65 and receiving hospice care, passed away shortly after the administration.
The facility failed to ensure timely physician visits for four residents following their admission, as required by policy. The physician did not evaluate the residents within 30 days of admission, with delays ranging from 42 to 57 days. The residents had various medical conditions requiring timely oversight, but the facility did not adhere to its policy, leading to a deficiency in care.
Failure to Ensure Resident Safety and Conduct Risk Assessments
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistive devices to prevent accidents. This deficiency was highlighted by an incident involving a resident who was severely cognitively impaired and had a history of falls. The resident was found stuck between his bed and a transfer pole, which had been installed without a prior safety risk assessment. The resident was discovered in a compromised position, displaying agonal breathing and was unresponsive, leading to a situation of immediate jeopardy. Further investigation revealed that the facility had not conducted safety risk assessments for 17 other residents who had transfer poles installed. Many of these residents were identified as having severe cognitive impairments and were at high risk for falls. Despite the presence of transfer poles, there were no physician's orders or documentation in the care plans for these devices, and no safety risk assessments had been completed to ensure their safe use. Additionally, the facility failed to prevent multiple falls, complete assessments after falls, and update fall care plans for several residents. There was also a failure to ensure a resident did not smoke while using an oxygen cannula, posing a significant safety risk. Interviews with staff revealed a lack of clarity and training regarding the proper assessment and placement of transfer poles, further contributing to the unsafe environment.
Removal Plan
- Physical therapy (PT) staff completed evaluations for each resident with access to a transfer pole.
- Evaluations included proper placement as well as resident conditions that may affect transfer, any risks for entrapment for all residents with access to transfer pole.
- Assessments included: General assessment: fall risk, cognition, transfer ability and other comorbidities that may affect ability to safely use assistive or transfer devices by PT; Bedside: to include transfer ability with multiple assistive devices to determine safest option for individual resident need.
- PT to establish the distance from bed to appropriate assistive device and determine safest distance based on individuality of the resident and manufacturer's recommended use.
- Assessment will include mechanics of the bed, including possible mattress and wheel shift; Placement considered safe and appropriate by PT from beside and bathroom individual evaluation as evidenced by distance deemed safe and beneficial through multiple transfer trials with PT to determine the resident's specific body habitus.
- 15-minute checks performed by direct care staff on shift until evaluation or assessment is completed by therapy and further determination is made.
- Education of nursing staff will be provided by director of nursing (DON), infection preventionist (IP) or lead CNA prior to staff's next scheduled shift.
- Lead CNA educated by DON.
- Education includes: 15-minute checks and resident safety for residents for increased fall risk and for the residents that still have access to a transfer pole.
- If a new transfer or assistive device is implemented, the above staff will continue to educate front line staff, housekeeping and maintenance.
- Beds will be marked and staff educated to ensure appropriate placement.
- Will monitor placement of device installed in relation to the mattress, if the device is at bedside, an order obtained from PT every shift by nursing, daily safety rounds by restorative and quarterly by therapy and as needed.
- Resident's bed and any furniture in close proximity to the device will be marked on the floor to ensure proper replacement of furniture should it need to be temporarily moved.
- Will continue to encourage call light use.
- For those residents whose transfer pole was removed, staff have been educated to provide 15-minute checks, offer transfer assistance and encourage call light use education provided to direct care staff to continue with 15-minute checks until the interdisciplinary team (IDT) determines they are no longer needed to ensure safety.
- Encourage residents to use call light to request assistance and staff to provide transfer assistance as indicated.
- Any new transfer pole request will not be ordered or initiated until therapy completes and evaluation to determine appropriateness.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for a resident, identified as Resident #54. This resident was admitted with multiple diagnoses, including type 2 diabetes, a history of toe amputation, osteomyelitis, and neuropathy. Despite having physician's orders for offloading pressure-relieving boots, the resident did not consistently wear them, and her refusals were not documented or addressed in her care plan. Consequently, the resident developed a blister on her left heel, which progressed into an unstageable pressure ulcer. Additionally, a potential second pressure wound was identified on her right lateral foot. The facility's failure to ensure effective interventions and monitor compliance contributed to the resident's condition. Observations revealed that the resident was often not wearing her heel protective boots, both in bed and while using her wheelchair. The resident expressed discomfort with the boots, citing issues such as the boots getting tangled in her wheelchair and discomfort from a screw on the wheelchair foot pedal. Despite these complaints, the facility did not investigate or adjust the resident's wheelchair or foot pedals to accommodate the boots better. Interviews with staff, including the wound care nurse (WCN) and the director of nursing (DON), indicated a lack of documentation and care planning regarding the resident's refusal to wear the boots. The WCN acknowledged that the resident's concerns about the boots were not addressed in the care plan, and there were no interventions in place for when the resident refused the boots. The facility's records, including the medication administration record (MAR) and treatment administration record (TAR), did not reflect the active order for the use of heel protective boots, nor did they track the administration and use of the ordered heel protection.
Ineffective QAPI Program Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to identify and address multiple concerns related to quality of care, including accidents and hazards. Specifically, the facility did not conduct safety risk assessments for residents with transfer poles, which led to a situation of immediate jeopardy where a serious adverse outcome was likely. The QAPI committee did not recognize the need to document and ask enough questions to determine the full factors or causes of falls, and they did not review smoking with a nasal cannula or the lack of safety assessments for transfer poles. The facility's QAPI committee met monthly, involving managers, the medical director, the pharmacist, and a licensed social worker from a sister facility. However, the committee failed to effectively identify and address concerns such as fall prevention, smoking hazards, and pressure ulcer prevention. The Director of Nursing (DON) acknowledged that the process failed because the committee did not recognize what needed to be documented and did not ask enough questions to determine the full factor or cause of the falls. Additionally, the committee did not review the residents' transfer poles and lack of safety assessments, nor did they identify the assessments were not completed prior to the installation of the transfer poles. Other deficiencies included the failure to maintain an effective water management plan, protect residents from physical abuse, maintain appropriate temperatures in medication and vaccine refrigerators, and provide bathing per resident preferences. The facility also failed to use medically rated blood pressure cuffs and ensure residents were served food in a form designed to meet their needs per physician's orders. The QAPI committee did not review these issues, and the Nursing Home Administrator (NHA) admitted that the facility had not looked at the lack of education provided to temporary traveling staff, which contributed to the deficiencies.
Inadequate Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in implementing a water management plan to prevent the growth and transmission of Legionella. According to the CDC guidelines, facilities should frequently monitor temperature, disinfectant residuals, and pH levels, and adjust the frequency of these measurements based on performance indicators. The guidelines also recommend flushing low-flow piping runs and dead legs at least weekly. However, the facility did not document the flushing of dead legs and low-flow piping runs in three hallways where residents resided. Additionally, seven rooms available for resident use had been vacant for seven or more consecutive days, indicating a potential lapse in maintaining water quality. Interviews with facility staff revealed discrepancies in the understanding and implementation of the water management plan. The Director of Maintenance (DOM) and the Nursing Home Administrator (NHA) stated that water in empty rooms was flushed every two weeks, which they believed was sufficient to prevent Legionella growth. However, the Infection Preventionist (IP) and the Director of Nursing (DON) were not directly involved in the water management plan and believed that weekly flushing was necessary to prevent the spread of waterborne pathogens. This lack of coordination and adherence to recommended guidelines contributed to the deficiency in the facility's infection control program.
Failure to Maintain Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards, specifically in two of three medication storage refrigerators. The deficiency was identified through a review of records and staff interviews, revealing that the facility did not maintain a consistent temperature log for both the vaccine and medication refrigerators. According to the Centers for Disease Control (CDC) guidelines, it is essential to keep storage units and vaccines within appropriate temperature ranges and to check and record storage unit minimum and maximum temperatures at the start of each workday. However, the facility's records showed that out of 50 days, the vaccine refrigerator temperatures were documented on only 16 days, and the medication refrigerator temperatures were documented on only 24 days. Interviews with staff, including a registered nurse (RN) and the director of nursing (DON), confirmed the lack of consistent documentation. RN #1 acknowledged that the medication and vaccine refrigerator temperatures should be logged every night by night shift nurses, but many days were missing from the logs. The DON also confirmed that all floor nurses were responsible for recording these temperatures and acknowledged the gaps in documentation. The DON emphasized the importance of daily documentation to ensure medications are stored safely and remain effective for resident use.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, specifically physical abuse by a staff member and verbal abuse between residents. Resident #12 alleged that a male CNA held his arms while another staff member changed him against his will. The resident reported the incident, and an investigation was initiated. The investigation revealed that the CNA admitted to holding the resident's arm to prevent him from hitting another staff member. The facility's documentation did not find physical abuse occurred due to a lack of consistent injuries, but the CNA was terminated due to concerns about rough handling. In another incident, Resident #52 and Resident #26 were involved in a physical altercation while attempting to elope from the facility. The altercation was observed by staff and captured on camera footage. The facility's investigation concluded that abuse was unsubstantiated as there was no evidence of bodily injury or fear. However, staff statements indicated that the residents pushed and poked each other during the incident. The facility's policies and procedures were not adequately followed, as evidenced by the lack of training and documentation for temporary staff. CNA #2 did not sign the facility's abuse policy, and both CNAs involved in the incident with Resident #12 did not attend relevant training sessions. The facility's failure to ensure staff were properly trained and aware of policies contributed to the deficiencies in protecting residents from abuse.
Failure to Provide Bathing Assistance Per Resident Preference
Penalty
Summary
The facility failed to provide bathing assistance according to the preferences of a resident who was unable to perform activities of daily living independently. The resident, who was under 65 years old and diagnosed with paraplegia, congestive heart failure, and generalized muscle weakness, was cognitively intact and expressed a preference for receiving two baths per week. However, since her admission, she had only received one bed bath, which did not meet her stated preference. The resident expressed concerns about her hygiene, particularly her greasy hair, and felt sad about her extensive care needs potentially impacting the care of other residents. The facility's documentation and interviews with staff revealed inconsistencies and a lack of proper documentation regarding the resident's bathing preferences and the level of assistance required. The comprehensive care plan did not include the resident's bathing preferences, and the facility's records showed that the resident was unavailable for preference discussions on multiple occasions. Despite the facility's policy of providing two baths per week or according to resident preference, the resident only received two baths in a 14-day period, which was acknowledged by the Director of Nursing as insufficient.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to provide food and fluids prepared in a form designed to meet the needs of two residents, as per speech therapy recommendations, physician's orders, and the residents' care plans. Specifically, the facility did not serve food in the correct form for two residents who were prescribed a mechanically altered diet texture. The facility's policy and procedure, as well as the diet manual, outlined specific requirements for mechanically altered diets, including the need for ground or minced meats and pureed or gelled breads. Resident #43, who was diagnosed with dementia, acute cough, and dysphagia, was observed being served a Salisbury steak and a dinner roll cut into bite-sized pieces, rather than the required ground Salisbury steak and pureed or gelled bread. Similarly, Resident #14, diagnosed with dementia, Parkinsonism, and dysphagia, was also served a regular textured Salisbury steak and a dinner roll cut into bite-sized pieces, contrary to the prescribed mechanically altered diet. Both residents' electronic medical records did not indicate any dietary waivers allowing them to consume regular textured food. Interviews with facility staff revealed a lack of awareness regarding the specific dietary requirements for mechanically altered diets. The dietary aide and cook were unaware that bread needed to be pureed or gelled, and the registered dietitian acknowledged that the facility had not yet implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) program. The registered dietitian also confirmed that the Salisbury steak should not have been formed into a steak shape and cut into bite-sized pieces, but rather served as ground beef with gravy.
Use of Non-Medically Rated Blood Pressure Cuffs
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically by using blood pressure cuffs not rated for medical use. Observations revealed that an LPN and an RN used wrist-type blood pressure cuffs, the Veridian Healthcare model 01-574 and the W1101L, respectively, to take blood pressure readings of residents. These devices were not verified as medically rated, as confirmed by the Director of Nursing (DON), who could not find manufacturer's instructions indicating their medical rating. Interviews with staff, including LPNs and the DON, revealed a lack of awareness regarding the medical rating of the blood pressure cuffs used. The LPNs admitted to using these cuffs without knowing if they were medically rated, and the DON acknowledged obtaining the cuffs from a medical supply company without verifying their suitability for medical use. The DON expressed surprise upon learning that the devices were not rated for medical use, emphasizing the importance of using medically rated equipment to ensure accurate vital sign readings for residents.
Significant Medication Error Due to Incorrect Morphine Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a registered nurse (RN) administered an incorrect dose of morphine sulfate solution. The error occurred because RN #1 did not perform a dosage check on the medication obtained from the facility's backup medication stock, which had a different concentration than the prescribed order. The nurse assumed the concentration was the same as the facility's standard stock and administered 3.75 ml of a 20 mg/1 ml concentration, resulting in the resident receiving 75 mg of morphine instead of the prescribed 15 mg. The resident involved was over the age of 65 and had been admitted with diagnoses including congestive heart failure, atrial fibrillation, aortic stenosis, pulmonary hypertension, and chronic pain. The resident was moderately cognitively impaired and receiving hospice care. On the day of the incident, the resident was unable to swallow oral medication, prompting a change in the prescription to liquid morphine sulfate. The nurse failed to verify the concentration of the medication with the physician's order, leading to the administration of an excessive dose. The error was discovered after the resident's condition changed, and the resident passed away shortly after receiving the incorrect dose. Interviews and record reviews confirmed that the nurse did not follow the seven rights of medication administration, which contributed to the significant medication error. The facility's investigation revealed that the nurse did not read the order or perform a dosage check, assuming the order matched the concentration available in the backup medication stock.
Failure to Ensure Timely Physician Visits for New Admissions
Penalty
Summary
The facility failed to ensure timely physician visits for four residents following their admission, as required by their policy. The policy mandates that a physician should see a resident within 30 days of initial admission. However, the records revealed that the physician did not evaluate Resident #9 until 57 days after admission, Resident #12 and Resident #13 until 47 days after admission, and Resident #10 until 42 days after admission. This delay in physician evaluation was identified during a review of the electronic medical records of these residents. The residents involved had various medical conditions that required timely medical oversight. Resident #9 had heart failure, atrial fibrillation, and other conditions, while Resident #12 had hypertension and neuropathy, among others. Resident #13 had dementia and other psychiatric and medical conditions, and Resident #10 had heart failure and dementia. Despite these conditions, the facility did not adhere to its policy of ensuring physician visits within the stipulated timeframe, leading to a deficiency in care. Interviews with the Director of Nursing and the Medical Director confirmed the issues with scheduling timely physician visits.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rifle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand River Health Care Center | 0.5 mi | — | 9 | 1 |
| Glenwood Springs Healthcare | 24 mi | — | 3 | 0 |
| Heritage Park Care Center | 30.5 mi | — | 0 | 0 |
| Walbridge Memorial Convalescent Wing | 36.7 mi | — | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.