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 River Valley Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen refrigerator were not labeled or dated as required, with some items expired and improperly stored, such as uncovered pork loins. Additionally, unsanitary conditions were observed, including a dirty refrigerator and a hot cocoa machine with visible debris and residue. Both the dietary manager and NHA confirmed these practices did not meet required standards for food safety and sanitation.
The facility failed to ensure that call lights were within reach for four residents, compromising their ability to call for assistance. Residents with cognitive impairments and physical limitations were observed with call lights out of reach, leading to feelings of helplessness and reliance on calling out for help. Staff interviews confirmed the expectation that call lights should be accessible, yet this was not consistently achieved.
A facility failed to ensure residents received care from qualified staff, as a medical records assistant, also a CNA, improperly handled physician's orders for 11 residents. The orders included medications, therapy evaluations, and dietary instructions, which should have been managed by qualified nursing staff. Interviews revealed that facility leadership was unaware of this practice, which violated care standards.
The facility failed to ensure proper hand hygiene in the kitchen, as observed when a cook repeatedly changed gloves without washing hands between tasks, violating both facility policy and state regulations. This included handling food, utensils, and interacting with residents, increasing the risk of cross-contamination. Interviews confirmed the expectation for handwashing between glove changes, highlighting a lapse in adherence to hygiene protocols.
A resident was verbally abused by a CNA, who was also their son, during a forced shower. The CNA used inappropriate language, which was witnessed by other staff. The resident, with a history of stroke and depression, initially denied abuse but later confirmed feeling afraid and sad. The facility's investigation corroborated the abuse, leading to the CNA's suspension and termination.
A resident did not receive prescribed lidocaine patches for pain management due to unavailability, and daily dressing changes for a wound were missed despite orders. The facility failed to notify the provider about these issues, leading to a deficiency in care. Staff interviews revealed a lack of communication and clarity in following physician orders.
A resident with multiple health conditions and specific snack preferences was not provided with grapes, a preferred snack, due to the facility's failure to update food orders and accommodate preferences. The dietary manager was not trained on obtaining preferences or placing orders, leading to a lack of preferred snacks like grapes and butterscotch pudding.
A facility failed to properly disinfect glucometers between uses, as a nurse used only one wipe instead of two and did not adhere to the required two-minute wet contact time. This practice did not align with the manufacturer's guidelines, leading to a deficiency in the infection control program.
A resident with severe cognitive impairment and physical limitations did not receive the appropriate level of assistance for transfers and positioning. Despite therapy recommendations for two-person assistance or a hoyer lift, the resident was transferred with only one staff member. The care plan was not updated to reflect these needs, and there was a lack of communication and documentation among staff regarding the resident's care requirements.
The facility did not complete performance reviews for two CNAs within the required 12-month period, nor did it provide regular in-service education based on these reviews. The DON, responsible for these tasks, confirmed the oversight, and the NHA acknowledged that reviews were not conducted as per policy.
The facility's medication error rate was 5.88%, exceeding the acceptable threshold. An RN failed to prime an insulin pen correctly, administering insulin to a resident without following the manufacturer's instructions. Additionally, a CNA-Med could not administer the correct dose of aripiprazole to a resident due to the unavailability of the appropriate tablet dosage.
A resident with diabetes received an incorrect dose of insulin due to a nurse's failure to prime the insulin pen correctly. The nurse primed the pen with one unit instead of the recommended two units, leading to a potential medication error. The resident was cognitively intact and required supervision for certain activities.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and sanitation practices. During a kitchen tour, several food items in the main kitchen refrigerator were found without required open dates, including coleslaw, an unknown meat, peaches, red sauce, half an avocado, celery, dressing, and muffins. Additionally, two items—an unknown meat and a bag of lettuce—were found to be expired. Two large pork loins were stored on the bottom of the refrigerator without being placed in a covered pan. The dietary manager confirmed that staff had not dated the items as required, that food should only be stored for five days, and that the expired items should have been discarded. The pork loins were not properly covered, which could lead to cross-contamination. Further observations revealed unsanitary conditions in both the main kitchen and the main dining room. A yellow, powdery substance was found covering a large area on the bottom of the refrigerator. The hot cocoa machine in the main dining room had visible debris, with the dispensing tube dirty and specked with cocoa, and a large amount of loose cocoa inside the machine. Both the dietary manager and the nursing home administrator acknowledged that the refrigerator and cocoa machine should have been cleaned daily to maintain sanitary conditions and prevent foodborne illness.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for four residents were within reach, compromising their ability to call for assistance. Resident #3, who had severe cognitive impairments and was dependent on staff for assistance, was observed with her call light out of reach while seated in her bedside chair. Her care plan emphasized the importance of having the call light within reach due to her risk of falls and cognitive impairments. Resident #39, with severe cognitive impairments and requiring assistance with daily activities, was repeatedly observed with her call light on the floor and out of reach. Despite her care plan's directive to keep assistive devices within reach, she was unaware of the call light's location and expressed that she would get up to ask for help if needed. Resident #49, who was cognitively intact but had impairments in both upper and lower extremities, reported feeling helpless when unable to reach his call light. He frequently found his call light in inaccessible locations, such as in a dresser drawer or clipped to the side of his bed, leading him to call out for help. Similarly, Resident #51, with severe cognitive impairments and requiring substantial assistance, was observed with her call light on the floor, out of reach while she was in her wheelchair. Staff interviews confirmed that call lights should be within reach and not on the floor, yet this standard was not consistently met.
Unqualified Staff Handling Physician Orders
Penalty
Summary
The facility failed to ensure that residents received care from qualified employees, as evidenced by the involvement of a medical records assistant (MRA) in creating, confirming, and revising physician's orders for multiple residents. This deficiency was identified for 11 residents, where the MRA, who was also a certified nursing assistant (CNA), was found to have entered and confirmed various physician's orders, which is outside the scope of practice for a CNA. The orders included medications, therapy evaluations, dietary instructions, and other medical directives. The review of computerized physician orders (CPO) for the residents revealed that the MRA was responsible for handling orders related to medications such as Tylenol and Amlodipine, dietary modifications, therapy referrals, and other medical instructions. These actions were not in compliance with the facility's policy, which requires that only qualified nursing staff handle such orders. The orders were created and confirmed by the MRA without the necessary qualifications, leading to a breach in the standard of care expected in the facility. Interviews with the nursing home administrator (NHA) and the director of nursing (DON) confirmed that they were unaware of the MRA's involvement in handling physician's orders. They acknowledged that CNAs are not permitted to create, confirm, or revise physician's orders, as it is not within their scope of practice. This oversight resulted in a failure to provide care by qualified persons according to each resident's written plan of care, as required by regulatory standards.
Failure to Maintain Proper Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain proper hand hygiene practices in the main kitchen, as observed during a lunch meal service. Cook #1 was seen repeatedly changing gloves without washing hands between tasks, which is a violation of both the facility's hand hygiene policy and the Colorado Retail Food Establishment Regulations. These regulations require that food employees must not contact exposed, ready-to-eat food with bare hands and must use suitable utensils or single-use gloves, which should be changed between tasks and after any interruptions. During the observation, Cook #1 engaged in multiple tasks such as sanitizing work areas, handling dirty dishes, slicing meatloaf, preparing instant mashed potatoes, and plating meals, all without washing hands between glove changes. This included actions like reaching into pockets, handling meal tickets, and interacting with residents, which further increased the risk of cross-contamination. Despite being reminded by the regional director of dietary services consultant to change gloves, Cook #1 continued to neglect proper hand hygiene practices. Interviews with the dietary manager and the regional director of dietary services consultant confirmed that the staff should wash their hands before putting on gloves and after removing them, and gloves should be changed between tasks. However, it was unclear why Cook #1 did not adhere to these protocols, indicating a lapse in following established hand hygiene procedures. The dietary manager acknowledged the need for staff education on hand hygiene to prevent such deficiencies in the future.
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a certified nurse aide (CNA). The incident involved a resident who was forced to take a shower against their will by CNA #7, who was also the resident's son. During the incident, the CNA used inappropriate language, telling the resident to stop crying and using expletives. This was witnessed by another CNA and a licensed practical nurse (LPN), who reported the verbal abuse. The resident was observed crying after the incident, and although they initially denied any abuse, they later confirmed feeling afraid and sad due to the CNA's actions. The resident involved in the incident was a 65-year-old with a history of stroke, right-side paralysis, and depression. They had moderately impaired cognition and were dependent on staff for transfers, showers, and toileting. The resident used a manual wheelchair and had no history of rejecting care. Despite the resident's initial denial of abuse, the facility's investigation revealed that the verbal abuse had occurred, as corroborated by staff witnesses. The facility's investigation included interviews with other residents, family members, and staff, as well as random skin assessments of residents. No additional concerns were identified during these assessments. The CNA involved was suspended immediately following the incident and later terminated. The facility had policies in place for abuse prevention and reporting, and staff received training on these policies during orientation and ongoing education sessions.
Failure to Administer Pain Medication and Dressing Changes
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one resident. Specifically, the facility did not follow the physician's orders for pain management and wound care. The resident, who was cognitively intact and had a history of heart failure, osteoarthritis, and osteoporosis, did not receive the prescribed lidocaine patches for pain management on multiple occasions in October 2024 because the medication was not available. There was no documentation in the electronic medical record indicating that the provider was notified about the unavailability of the medication. Additionally, the facility did not complete the daily dressing changes for the resident's right lower extremity as ordered by the physician. The dressing changes were missed on specific dates in December 2024, with progress notes indicating that the site was healed. However, there was no documentation in the resident's electronic medical record to confirm that the provider was notified about the healing of the site. Interviews with staff, including a CNA with medication authority and the DON, revealed a lack of clarity and communication regarding the administration of medications and wound care. The CNA was unaware of the reasons for the unavailability of the lidocaine patches and the missed dressing changes. The DON acknowledged that the orders should have been clearer and that the provider should have been contacted if the medication was not available or if the wound was healed. The NHA also noted that the facility should have ensured the resident received her medication by exploring alternative options.
Failure to Provide Resident's Preferred Snacks
Penalty
Summary
The facility failed to provide meals according to a resident's preferences, specifically for a resident who expressed a preference for grapes as a snack. Despite the resident's clear preference and the facility's proximity to a grocery store, grapes were not available, and no alternative was provided. The resident, who was cognitively intact, expressed frustration over the lack of effort from the dietary department to accommodate his preference. The resident, under 65 years old, had multiple diagnoses including type 2 diabetes, cerebral infarction, hemiplegia, hemiparesis, COPD, epilepsy, depressive episodes, and anxiety. The resident's care plan indicated a risk for altered nutritional status and emphasized the importance of keeping food preferences up to date. However, the facility did not have grapes available, and the dietary aide offered snacks that the resident did not prefer or could not eat due to dental issues. Interviews with the dietary manager revealed that the facility had not been ordering enough snacks, and the new dietary manager had not been trained on obtaining resident preferences or placing food orders. The previous dietary manager's order list, which did not include grapes, was still being used. The dietary manager acknowledged the importance of providing snacks that residents liked, as it was their home, but admitted that the facility had been out of certain preferred items like grapes and butterscotch pudding for some time.
Inadequate Disinfection of Glucometers
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in the cleaning and disinfection of glucometers used for blood glucose monitoring. Observations revealed that a registered nurse (RN) used an unlabeled glucometer on multiple residents without following proper cleaning and disinfection protocols. The RN used only one Super Sani Cloth germicidal wipe instead of the required two wipes, and did not adhere to the two-minute wet contact time necessary for effective disinfection as per the manufacturer's guidelines. Interviews with the RN indicated a lack of awareness regarding the correct disinfection time and procedure for the glucometers. The facility's policy and the manufacturer's recommendations both emphasize the importance of cleaning and disinfecting the glucometers after each use to prevent the spread of blood-borne pathogens. Despite this, the RN's practice did not align with these guidelines, leading to a deficiency in the infection control program.
Failure to Provide Adequate Assistance and Update Care Plan for Resident
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with severe cognitive impairment and physical limitations. The resident, who had a history of cerebral infarction and dementia, required substantial assistance with activities of daily living (ADLs), including transfers and positioning. Observations revealed that the resident was often left in positions that could compromise her comfort and safety, such as leaning to one side in bed and in her recliner. Despite recommendations from physical and occupational therapy for maximum assistance or the use of a hoyer lift for transfers, the resident was observed being transferred with the assistance of only one staff member. The resident's care plan was not updated to reflect the necessary level of assistance for transfers and positioning as recommended by therapy discharge instructions. The care plan indicated one-person assistance for transfers, contrary to the physical therapy discharge summary, which recommended two-person assistance or a hoyer lift. Additionally, there was no documentation of nursing staff providing range of motion exercises during ADLs or implementing personalized positioning interventions, as recommended by occupational therapy. Interviews with staff revealed a lack of communication and documentation regarding the resident's care needs. The physical therapy assistant noted that education on the resident's transfer and positioning needs was provided to certified nurse aides, but there was no formal documentation of this training. The director of nursing and the nursing home administrator acknowledged the absence of a process to ensure continuity of care between therapy and nursing staff, which contributed to the deficiency in providing appropriate care for the resident.
Failure to Conduct Timely Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct a performance review for two certified nurse aides (CNAs) within the required 12-month period and did not provide regular in-service education based on these reviews. Specifically, CNA #2, hired on August 1, 2019, and CNA #4, hired on May 1, 2023, did not have documented performance reviews completed in the past 12 months. This deficiency was identified through record reviews and staff interviews. The Director of Nursing (DON), who assumed the role in October 2024, acknowledged the responsibility for completing these reviews and in-service education. The Nursing Home Administrator (NHA) confirmed that performance reviews were not completed for the two CNAs, which was contrary to the facility's policy of conducting reviews based on the CNAs' start dates.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.88% due to two errors out of 34 opportunities. One error involved a registered nurse (RN) who did not prime a Lispro insulin pen with the manufacturer's recommended two units before administering five units of insulin to a resident. The RN primed the pen with only one unit, contrary to the manufacturer's instructions, which could lead to incorrect dosing. The RN was unaware of the correct priming procedure, as she had been taught to use one unit for priming. Another error occurred when a certified nurse aide with medication authority (CNA-Med) was unable to administer the correct dose of aripiprazole to a resident because the appropriate five mg tablets were unavailable. The CNA-Med found only ten mg tablets, which were unscored, and therefore could not be split to achieve the correct dosage. The medication was held, and the nurse at the desk was informed to order the correct dosage and notify the provider of the situation.
Insulin Administration Error Due to Incorrect Priming
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. A registered nurse (RN) did not follow the manufacturer's instructions for priming an insulin pen before administering a dose to a resident. The RN primed the pen with one unit of insulin instead of the recommended two units, as per the manufacturer's guidelines. This incorrect priming could lead to the resident receiving an incorrect dose of insulin. The resident involved was an 85-year-old with a diagnosis of type 2 diabetes mellitus and hypertension. The resident was cognitively intact and required supervision for certain activities. The RN, unaware of the correct priming procedure, followed a practice she was taught, which was not aligned with the manufacturer's instructions. The nursing home administrator was also initially unaware of the correct priming procedure but later acknowledged the correct method as per the manufacturer's recommendations.
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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 Del Norte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rock Creek Rehabilitation And Healthcare Center | 14.3 mi | — | 3 | 0 |
| Colorado Veterans Community Living Ctr At Homelake | 15.4 mi | — | 0 | 0 |
| San Luis Care Center | 28.7 mi | — | 0 | 0 |
| Evergreen Nursing Home | 29 mi | — | 2 | 0 |
| Rio Grande Rehabilitation And Healthcare Center | 35.3 mi | — | 15 | 1 |
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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.