Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 South Valley Post Acute Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep resident water temperatures within safe limits and did not ensure proper transfer assistance for a high‑risk resident. Multiple resident room sinks were measured with hot water above 120°F despite a policy limiting temperatures to prevent scalding, and monitoring focused on a small sample of rooms and shower areas. CNAs primarily checked water by touch, and thermometers were not consistently available in shower rooms. Separately, a resident with cauda equina syndrome, right‑sided hemiplegia, and significant weakness, who was care‑planned for a gait belt and two‑person assist for transfers, was transferred by a single CNA who was unaware of the updated two‑person requirement, resulting in the resident’s legs giving out and an assisted fall to the floor.
The facility failed to maintain a clean and sanitary environment in one of the three units reviewed. Observations revealed soiled floors, walls, and furniture, as well as a lack of clean linens. Resident and staff interviews confirmed inadequate housekeeping practices and staffing issues. The facility's improvement plan did not address all observed deficiencies.
Unsafe Hot Water Temperatures and Improper Transfer Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident water temperatures within safe bathing limits and to ensure appropriate transfer assistance, resulting in unsafe environmental conditions and a resident fall. The facility’s written Water Temperatures policy required tap water to be kept within a range that prevents scalding, with water heaters set to no more than 120°F and periodic tap water checks documented in a safety log. Despite this, surveyors measured hot water temperatures in multiple resident room sinks that exceeded 120°F, including readings of 133°F, 125.2°F, 126.9°F, 126.7°F, and 124.7°F. The facility’s own monitoring logs showed weekly checks in shower rooms and a small sample of resident rooms, with typical shower temperatures documented between 113°F and 117°F, and some readings below 100°F, indicating inconsistent temperature control. During the survey, the maintenance director reported that he checked each floor’s water temperatures weekly in shower rooms and one to two resident rooms per floor, aiming to keep temperatures below 120°F. He described his method of running showers for five minutes and using the same temperature probe each week. However, when he rechecked temperatures with surveyors present, several resident room sinks again showed hot water at or above the 120°F threshold, including 126.8°F, 123.8°F, 122°F, 123.8°F, and 120.2°F. Staff interviews revealed that CNAs relied primarily on testing water with their hands and resident feedback, and thermometers were not consistently available in shower rooms. CNAs believed maintenance checked temperatures more frequently than the logs reflected, and there were reports of prior concerns about inconsistent hot water during showers. The deficiency also includes a failure in fall management related to a resident with significant neurological and mobility impairments. Resident #2, an older adult with cauda equina syndrome, right-sided hemiplegia and hemiparesis following a stroke, a colostomy, and bladder cancer, was cognitively intact but dependent on staff for toileting and chair-to-bed transfers. The resident had an identified risk for falls due to impaired mobility, weakness, pain, and multiple neurologic conditions, and her care plan included an intervention for staff education on the use of a gait belt and two-person assist for transfers because of severe weakness from cauda equina syndrome. On the date of the incident, the resident sustained a witnessed fall during a morning transfer when her legs gave out and she slid from the edge of the bed to the floor. The incident report did not identify which CNA was involved, but records showed CNA #5 was working with the resident that day. Further review and interviews established that CNA #5 attempted to transfer the resident from bed to wheelchair alone, using a gait belt and with the resident wearing non-slip socks. CNA #5 reported that the resident appeared wobbly and weak, and that she tried to sit the resident back on the bed before assisting her to the ground. CNA #5 stated that the resident usually required one-person assistance for transfers and was not aware that the resident had become a two-person assist. The DON later confirmed that the new intervention designating the resident as a two-person transfer had not been transcribed onto the CNA task list, which resulted in CNA #5 not knowing the resident’s updated transfer status at the time of the fall. This breakdown in communication and task transcription, combined with the resident’s known severe weakness and fall risk, led to the resident being transferred without the required level of assistance and experiencing a fall. Overall, the deficiency centers on two main areas: environmental safety related to hot water control and clinical safety related to fall prevention. In the first area, the facility did not consistently maintain hot water temperatures within the safe range specified in its own policy, and monitoring practices did not prevent multiple resident room sinks from reaching temperatures above 120°F. In the second area, the facility did not ensure that updated fall-prevention interventions—specifically the requirement for two-person assistance for a high-risk resident’s transfers—were effectively communicated and implemented at the CNA level, resulting in a one-person transfer and a subsequent fall.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary homelike environment in one of the three units reviewed. Observations during the survey revealed multiple deficiencies, including thick dried substances on hallway walls, soiled floors with various debris, and dining room tables with sticky residues. The common area furniture was in poor condition, with cracked and peeling artificial leather, making it impossible to clean and disinfect properly. Additionally, the dining area had a strong smell of body odor, and the floors were heavily soiled with black stains and dried substances. The walls and handrails in the common areas were chipped and soiled, and the nurses' station was dirty with dried liquid spills and garbage. The second-floor shower room was also found in an unsanitary condition, with standing water, soiled shower chairs, and hairbrushes with heavy hair buildup. Several resident rooms had heavily soiled floors, chipped walls, and stained privacy curtains. There was also a lack of clean linens, with some residents having to use paper towels due to the unavailability of cloth towels and washcloths. Resident interviews confirmed the lack of cleanliness and inadequate housekeeping practices, with residents expressing concerns about the dirty floors, stained privacy curtains, and unclean bathrooms. Staff interviews revealed that housekeeping struggled to maintain cleanliness due to staffing issues and inadequate cleaning methods. The maintenance director and housekeeping supervisor acknowledged the identified issues and mentioned ongoing and planned improvements, but the facility's improvement plan did not address all the observed deficiencies.
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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 Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rowan Community, Inc | 0.5 mi | — | 3 | 0 |
| Amberwood Post Acute | 0.6 mi | — | 4 | 0 |
| Brookshire Post Acute | 0.6 mi | — | 3 | 1 |
| Suites At Clermont Park Care Center, The | 0.7 mi | — | 8 | 0 |
| Holly Heights Care And Rehabilitation | 1.2 mi | — | 15 | 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.