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 Valley Manor Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering exited the facility undetected and was later found offsite by a CNA. The facility's care plan did not address elopement risk, and malfunctioning alarm and pager systems, along with inconsistent staff monitoring, contributed to the incident.
Two residents in an LTC facility experienced significant weight loss due to inadequate nutrition and hydration management. One resident, with severe protein-calorie malnutrition, lost 19% of their body weight over four months, while another resident with dementia experienced a 6.7% weight loss in three months. The facility failed to implement and document person-centered nutritional interventions, did not consistently monitor weights, and did not ensure adequate fluid intake. Staff interviews revealed issues with documentation accuracy and responsibility for monitoring nutritional intake.
The facility failed to address grievances regarding staff treatment, as residents reported CNAs being rough and rushing through care. Despite these concerns being raised in resident council meetings, there was a lack of documented follow-up or resolution. Resident interviews confirmed issues with staff attitudes and inadequate care, which were not effectively addressed by the facility's grievance process.
The facility failed to ensure proper hand hygiene during meal times in dining rooms and a kitchenette. Residents were not offered hand hygiene before meals, even after touching potentially contaminated surfaces. Staff, including Cook #3, did not consistently perform hand hygiene when handling food or after touching high-contact surfaces. Training records showed dietary staff received hand hygiene training, but it was not effectively implemented during meal service.
A facility failed to ensure a resident's legal representative signed the Medical Orders for Scope of Treatment (MOST) form. The resident, with severe cognitive impairment, had a Medical Durable Power of Attorney (MDPOA) document appointing two family members for medical decisions. However, the MOST form was signed by an unauthorized family member. Staff interviews revealed a lack of clear procedures for verifying the MDPOA, with responsibilities falling on floor nurses and no established process for confirmation.
Two residents with severe cognitive impairments were involved in a physical altercation, highlighting the facility's failure to prevent abuse. The care plans for both residents were not updated with effective interventions following the incident. Staff interviews indicated that resident-to-resident incidents were common due to dementia, and a lack of consistent activities, especially in the evenings, may have contributed to increased agitation and altercations.
A resident with dementia was inappropriately restrained using a gait belt by an RN, contrary to facility policy. The resident, who was at high risk for falls, was observed attempting to stand and walk but was repeatedly pulled back into her wheelchair by the RN. Staff interviews revealed a lack of awareness about specific fall interventions and inappropriate use of the gait belt, which was not reported by other staff members.
The facility failed to engage two residents with dementia in meaningful activities, leading to resident-to-resident abuse. Observations showed residents were often left unattended or asleep during activities, with minimal staff interaction. Care plans were not updated with effective interventions following altercations, and staff interviews revealed inconsistent activity provision, particularly during the evening shift.
The facility failed to discontinue PRN psychotropic medications after 14 days for two residents, contrary to its policy. One resident with Alzheimer's and dementia was prescribed Lorazepam for extended periods without physician documentation. Another resident with dementia and cerebrovascular disease was given Seroquel and Lorazepam beyond 14 days without justification. Staff interviews confirmed the lack of documentation for these extended prescriptions.
The facility failed to provide residents with food that was palatable and at safe temperatures. Residents reported issues with cold meals, tough meat, and overcooked vegetables. Observations confirmed improper food handling, with temperatures often below safe levels. Equipment malfunctions and staff training deficiencies contributed to the problem.
The facility failed to properly disinfect a shared mechanical lift and slings between residents, leading to a deficiency in infection control. Observations showed that the lift and sling were not cleaned after use with a male resident before being used for a female resident. Staff interviews revealed inconsistencies in infection control practices, with some staff believing disinfection was unnecessary if slings only touched clothing. The regional infection preventionist stressed the need for disinfection after each use, highlighting a gap in practice and understanding.
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to implement adequate interventions to prevent an elopement for a resident identified as high risk for elopement. The resident, who had severe cognitive impairment, dementia with behavioral disturbances, and a history of wandering and exit-seeking behaviors, was found off facility grounds in a supermarket parking lot by a CNA. The facility was unaware that the resident had left until notified by the CNA, who encountered the resident while off duty. The last known sighting of the resident within the facility was approximately an hour before the elopement was discovered. The facility's policies required elopement risk assessments and care planning for residents at risk of wandering or elopement. Although the resident's assessments and progress notes documented exit-seeking behaviors and a risk for elopement, the comprehensive care plan did not include a focus or interventions specifically addressing elopement risk. Additionally, there were gaps in monitoring at the front door, which was the exit point used by the resident. The front door was only alarmed with an audio alert during certain hours, and the pager system used to notify staff of door openings was not functioning correctly, only indicating the front door regardless of which door was opened. Staff interviews revealed that pagers were often ignored due to this malfunction, and there was not always staff present to monitor the front door. Observations during the survey also found that alarms on other doors were sometimes deactivated for convenience, and not always promptly reactivated, leaving those exits unmonitored. Staff interviews confirmed that the resident frequently wandered, especially in the afternoons, and that staff relied on informal methods to redirect him rather than consistent, documented interventions. The lack of a current, active care plan for elopement risk and the failure to ensure functioning alarm systems and adequate supervision directly contributed to the resident's ability to leave the facility undetected.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for two residents, leading to significant weight loss. Resident #17, diagnosed with chronic obstructive pulmonary disease, chronic respiratory failure, and severe protein-calorie malnutrition, experienced a severe weight loss of 19% over four months. Despite a physician's order to weigh the resident weekly, the facility did not consistently monitor the resident's weight. The only nutritional intervention implemented was a supplement, which was not consistently provided or documented. The care plan was not updated with person-centered interventions after the resident's weight loss. Resident #39, diagnosed with dementia, cardiomegaly, and chronic kidney disease, also experienced significant weight loss. The facility failed to document new interventions in the care plan after the weight loss was identified. The resident was not reweighed after issues with the scale were noted, and no additional interventions were implemented to prevent further weight loss. The facility did not ensure the resident consumed the estimated required amount of fluids to maintain physical function. Interviews with staff revealed a lack of clarity and responsibility regarding the documentation and monitoring of nutritional intake. The registered dietitian expressed concerns about the accuracy of documentation and the process for assessing the effectiveness of nutritional interventions. The director of nursing acknowledged the need for improved documentation and education to enhance resident record accuracy. The facility's failure to implement and document appropriate nutritional interventions contributed to the residents' significant weight loss and inadequate hydration.
Facility Fails to Address Resident Grievances on Staff Treatment
Penalty
Summary
The facility failed to effectively address and resolve grievances concerning staff treatment towards residents, as highlighted by the resident council meetings and individual interviews. Residents repeatedly expressed concerns about CNAs being rough, rushing through care, and not taking the time to ensure all their needs were met. Despite these grievances being raised in resident council meetings, there was a lack of documented follow-up or sustainable plans for resolution. The facility's grievance/concern tracking logs did not reflect these ongoing issues, indicating a failure in the grievance process. Resident interviews further corroborated the issues raised in the resident council meetings. Several residents reported that staff had an attitude, rushed through care, and did not communicate effectively. Some residents felt uncomfortable and neglected, as staff would leave them on the toilet for extended periods or fail to assist them fully before leaving the room. These interviews highlighted a pattern of inadequate care and communication from the staff, which was not adequately addressed by the facility's grievance process. The facility's internal processes for handling grievances were found to be lacking. The SSD and other staff members acknowledged that grievances were not consistently followed up on, and there was a decrease in grievance cards generated. The facility's QAPI meetings did not effectively address these concerns, and there was a lack of oversight in the grievance process. The facility's failure to document and follow up on grievances contributed to the ongoing dissatisfaction and unresolved concerns among residents.
Deficient Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to maintain proper hand hygiene practices during meal times in two of three dining rooms and one kitchenette. Observations revealed that residents were not offered hand hygiene before meals, even after touching potentially contaminated surfaces such as wheelchair wheels and walker handles. Hand hygiene supplies were not readily available on dining room tables, and staff did not encourage or provide hand hygiene to residents before they ate. In the memory care unit dining room, multiple instances were observed where residents were not offered hand hygiene before meals. Some residents used their hands to eat food after touching their noses or other potentially contaminated surfaces. Staff did not intervene when residents touched each other's food, increasing the risk of cross-contamination. Additionally, hand hygiene was not consistently performed by staff when handling food or after touching high-contact surfaces. Cook #3 was observed failing to perform hand hygiene after touching door handles and before handling food and clean dishes. The cook also did not wash hands before donning gloves to serve food. Training records indicated that dietary staff, including Cook #3, had received hand hygiene training, but the training did not appear to be effectively implemented during meal service. Interviews with staff and the regional infection preventionist highlighted the lack of a structured hand hygiene process before meals, contributing to the observed deficiencies.
Failure to Ensure Legal Representative Signed MOST Form
Penalty
Summary
The facility failed to ensure that a resident's legal representative was given the opportunity to exercise the resident's rights, specifically regarding the signing of the Medical Orders for Scope of Treatment (MOST) form. Resident #30, who had severe cognitive impairment due to Alzheimer's disease and dementia, had a Medical Durable Power of Attorney (MDPOA) document that legally appointed two family members to act on their behalf for medical decisions. However, the MOST form was signed by a family member who was not one of the designated MDPOAs, thus not legally authorized to make such decisions. Interviews with facility staff revealed a lack of clear procedures for verifying the MDPOA. Registered Nurse (RN) #1 admitted uncertainty in confirming the MDPOA's accuracy, while the Social Services Director (SSD) and Director of Nursing (DON) acknowledged that the responsibility for completing the MOST forms fell on the floor nurses during admission. The SSD noted that MOST forms were reviewed during care conferences but not routinely by social services, and the DON confirmed there was no established process for verifying the MDPOA, indicating a systemic issue in ensuring the correct legal representative was involved in decision-making.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from abuse, specifically in the case of two residents who were involved in a physical altercation. Resident #6, who was severely cognitively impaired and had a history of behavioral issues, physically abused Resident #66, who also had severe cognitive impairment and behavioral disturbances. The incident occurred when Resident #66 attempted to enter a room to use the bathroom, and Resident #6 responded by grabbing and slapping Resident #66. The facility did not assess the residents immediately after the incident to ensure there were no injuries, and the incident was not reported in a timely manner. The care plans for both residents were not updated with effective interventions to prevent further abuse. Resident #66's care plan included interventions for her dementia and behavioral issues, but it was not revised following the altercation to include personalized strategies to prevent future incidents. Similarly, Resident #6's care plan lacked a vulnerability care plan and an individual abuse prevention plan, failing to address the risk of resident-to-resident abuse. Interviews with staff revealed that resident-to-resident incidents were common in the memory care unit, attributed to the residents' dementia. Staff noted that keeping residents separated could help prevent incidents, but there was a lack of consistent activities, especially in the evenings, which may have contributed to increased agitation and altercations. The memory care coordinator acknowledged the need for more structured activities and supervision during the evening shift to reduce such incidents.
Inappropriate Use of Gait Belt as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically through the inappropriate use of a gait belt. The resident, identified as Resident #50, was observed repeatedly attempting to stand and walk, only to be restrained by a registered nurse (RN #2) using the gait belt to pull her back into her wheelchair. This occurred multiple times over a period of observation, with the nurse using the gait belt to prevent the resident from standing and walking, despite the resident's apparent desire and attempts to do so. The resident's care plan indicated she had unspecified dementia without behavioral disturbances and was at high risk for falls. However, the care plan did not include specific interventions for when the resident was constantly standing and sitting or when she pulled her wheelchair behind her as she walked. Staff interviews revealed that some staff members were aware of the inappropriate use of the gait belt but did not report it, and there was a lack of awareness about the specific fall interventions in place for the resident. The facility's policy on physical devices and bedrails emphasized that devices should only be used to treat a medical symptom or condition that endangers the resident's safety, with a physician's order and consent. The policy also stated that devices should not be used as restraints. Despite this, RN #2 used the gait belt in a manner that effectively restrained the resident, contrary to the facility's policy and the training provided to staff.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with dementia, specifically for two residents who were not engaged in meaningful activities, leading to resident-to-resident abuse. The facility's memory support program, which operates under a person-centered model, was not effectively implemented. Observations revealed that residents were often left unattended or asleep during activities, with minimal staff interaction. For instance, during a video activity about bees, most residents, including one of the affected residents, were asleep, indicating a lack of engagement. The care plans for the two residents involved were not updated with effective interventions following a resident-to-resident altercation. One resident, who had severe cognitive impairment and experienced hallucinations and behavioral symptoms, was not provided with meaningful activities as outlined in her care plan. The care plan included interventions such as crafts, religious shows, and outdoor activities, but these were not implemented effectively. Similarly, the other resident, who also had severe cognitive impairment and behavioral disturbances, was not engaged in activities that matched her interests, such as sports on TV, and her care plan was not updated to prevent further altercations. Interviews with staff revealed a lack of consistent activity provision, particularly during the evening shift. The activity aide assigned to the memory care unit admitted to waiting for activities to do, resulting in residents being left to sleep in recliners. The memory care coordinator acknowledged the need for more supervision during the evening shift, as this was when more problematic behaviors occurred. The director of nursing noted that the facility was trying to approve a dedicated activity aide position for the memory care unit to ensure residents received consistent and meaningful engagement.
Failure to Discontinue PRN Psychotropic Medications After 14 Days
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically regarding the use of PRN (as needed) orders for two residents. The facility's policy, revised in August 2023, states that PRN orders for psychotropic medications are limited to 14 days unless extended by a physician. However, the facility did not adhere to this policy for two residents, resulting in the administration of psychotropic medications beyond the 14-day limit without documented justification from a physician. Resident #30, an 87-year-old with Alzheimer's disease and dementia, was prescribed Lorazepam, an anti-anxiety medication, on a PRN basis for periods exceeding 14 days on multiple occasions. The medication was ordered for 90 days in June 2023, 90 days in October 2023, and 60 days in May 2024, without any documentation from a physician justifying the extended use. Similarly, Resident #21, who was over 65 years old and had dementia, cerebrovascular disease, and insomnia, was prescribed Seroquel and Lorazepam on a PRN basis for more than 14 days without documented justification. Interviews with facility staff, including the pharmacist, director of nursing, and corporate consultant, confirmed that there was no documented reason for the extended use of PRN psychotropic medications for these residents. The staff acknowledged that the facility's practice was against regulations, which require a documented reason for extending PRN psychotropic medication orders beyond 14 days.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, appearance, and temperature. Multiple residents reported issues with the meals served, including cold food, tough meat, overcooked vegetables, and a lack of seasoning. Observations during meal preparation and service confirmed these issues, with food temperatures often falling below safe levels, indicating improper handling and preparation. During observations, it was noted that the kitchen staff did not consistently maintain appropriate food temperatures. For instance, the temperature of the mashed potatoes, hamburger patties, and carrots were recorded below the required holding temperature, with some items falling into the danger zone. Additionally, the facility's steamer, which was crucial for maintaining food temperatures and preventing overcooking, was not functioning correctly, contributing to the issues with food quality. Interviews with staff revealed that there were ongoing concerns with food preparation and equipment maintenance. The dietary manager acknowledged the problems with food temperatures and preparation, citing issues with the steamer and the need for staff retraining. Communication barriers and insufficient oversight were also identified as contributing factors to the deficiency, with the charge cook requiring additional training to ensure proper cooking methods were followed.
Inadequate Disinfection of Shared Mechanical Lift and Slings
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper cleaning and disinfection of a shared mechanical lift and slings between residents on two units. Observations revealed that after a male resident was assisted to the bathroom using a mechanical lift with a small sling, the lift and sling were not wiped down before being returned to the common area. Subsequently, the same sling was used for a female resident without disinfection, and the mechanical lift was handed over to another staff member without being cleaned. Interviews with staff members highlighted inconsistencies in understanding and implementing infection control procedures. LPN #4 stated that mechanical lifts were cleaned at the end of each shift rather than after each use, and believed that slings did not require disinfection as they touched residents' clothes, not skin. In contrast, the memory care coordinator and other staff members acknowledged the need for disinfection after each use. The regional infection preventionist emphasized the importance of wiping down the lift and shared slings, regardless of whether they touched skin or clothing. This inconsistency in practice and understanding contributed to the deficiency in infection control.
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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 Montrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hope Springs Care Center | 0.6 mi | — | 0 | 0 |
| Colorow Care Center | 11.8 mi | — | 2 | 0 |
| Willow Tree Care Center | 20.4 mi | — | 14 | 0 |
| Horizons Care Center | 25.2 mi | — | 1 | 0 |
| Paonia Care And Rehabilitation Center | 31.2 mi | — | 0 | 0 |
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