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 Rehabilitation And Healthcare Center, The during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, and mobility impairments was injured during transport when a facility vehicle made a sudden stop, causing the seatbelt to come loose due to incompatible components. The resident fell from the wheelchair, sustaining a femur fracture that required surgery. Investigation confirmed the seatbelt was not properly secured, resulting in the resident not being protected during the incident.
A resident's representative did not receive requested medical records within the facility's required 48-hour timeframe due to an incorrect email address in the EMR and staff confusion about the policy timeline, resulting in a delay despite multiple requests and a valid authorization form.
The facility did not update care plans with new interventions after multiple falls for two residents, despite repeated incidents and injuries. Staff failed to revise fall prevention strategies in the care plans and Kardex, resulting in outdated guidance for CNAs and other staff. Interviews confirmed that recommendations discussed in meetings were not consistently documented, and the MDS coordinator acknowledged delays in updating care plans after changes in resident condition.
The facility failed to maintain sanitary conditions and safe food temperatures in the kitchen. Observations showed improper handling of ready-to-eat foods, with staff not changing gloves between tasks. Additionally, food items were served at unsafe temperatures, and nutritional supplements were stored above the safe range. Despite previous education, staff did not adhere to guidelines, and temperature logs were not maintained.
The facility failed to properly store and label medications on three of five units, with topical medications left unsecured in shower rooms and residents' rooms. Staff interviews confirmed that medications should be locked and only accessible to authorized personnel, highlighting a risk of unauthorized access.
The facility exhibited significant infection control deficiencies, including improper cleaning practices by housekeeping staff, unlabeled personal care items in shower rooms, and unsanitary management of a resident's urinary catheter. Housekeeping staff failed to follow proper cleaning protocols, such as maintaining disinfectant contact time and performing hand hygiene. Personal care items were found unlabeled, risking cross-contamination, and a resident's urinary catheter drainage bag was improperly placed on the floor.
Resident Injury Due to Improper Wheelchair Securement During Transport
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors, including dementia, osteoporosis, muscle weakness, difficulty walking, and a history of falls, was injured during transportation to a medical appointment. The resident, who required substantial to maximal assistance with mobility and used a wheelchair, was being transported in a facility vehicle operated by an activities assistant. During the trip, the driver had to make a sudden, hard stop to avoid an accident, which resulted in the resident's seatbelt becoming unfastened and the resident falling out of the wheelchair. Investigation revealed that the seatbelt used to secure the resident was not properly latched due to the use of non-compatible seatbelt components from different manufacturers. The driver believed the seatbelt was secure, but under force, it came loose, allowing the resident to be ejected from the wheelchair. The wheelchair itself was locked in place, but the improper securement of the seatbelt failed to protect the resident during the abrupt stop. As a result of the fall, the resident sustained a left femur fracture with intercondylar extension, skin tears, and required surgical intervention. The incident was confirmed through interviews, record reviews, and observations, which established that the facility failed to ensure the resident was free from accident hazards and did not provide adequate supervision or equipment compatibility to prevent the accident during transportation.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident's representative, as required by its own policy. The representative submitted a written, signed, and dated authorization for release of protected health information, requesting the resident's medical records. Despite multiple requests and the completion of the required authorization form, the representative did not receive the records within the facility's stated 48-hour timeframe. Interviews and record reviews revealed that the delay was due in part to a miscommunication regarding the format in which the records should be sent and an error in the resident representative's email address as documented in the electronic medical record (EMR) contact list. The social service director attempted to email the records using the incorrect email address, resulting in the representative not receiving the requested information. The business office manager and nursing home administrator later identified the error in the contact information. Staff interviews confirmed that the facility's policy required records to be provided within 48 hours of a valid request, but staff initially believed they had up to 30 days to fulfill the request. The error in the email address and the misunderstanding of the policy's timeline led to the failure to provide the records in a timely manner, as required by facility policy and federal regulations.
Failure to Revise Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that care plans were revised and appropriate for three out of four residents reviewed for comprehensive care plans. Specifically, the facility did not update or revise the fall care plans with new interventions after multiple falls occurred for two residents. For one resident, there were 11 falls out of 13 incidents where the care plan was not updated to include new interventions, despite documentation of unwitnessed and witnessed falls, some resulting in abrasions, skin tears, and hospital transfer. The care plan and Kardex did not reflect changes or new strategies to address the ongoing risk and incidents of falls, even though the facility's own policies required ongoing assessment and revision of care plans as residents' conditions changed or when desired outcomes were not met. Another resident experienced a fall, and the care plan was not updated to include new interventions following the incident. The fall care plan for this resident included interventions such as bed positioning, call light education, and non-skid footwear, but after the fall, no new interventions were added to the care plan. Staff interviews confirmed that recommendations and interventions discussed in meetings were not consistently added to the care plans or the Kardex, which are used by CNAs and other staff to guide resident care. The lack of timely updates to care plans meant that staff did not have access to the most current and individualized fall prevention strategies for these residents. Interviews with facility staff, including the NHA, DON, MDS coordinator, and CNAs, revealed inconsistencies in how fall interventions were communicated and implemented. Staff often relied on verbal communication or checked with nurses rather than referencing updated care plans or the Kardex. The MDS coordinator acknowledged that care plans were not always updated promptly after falls and that a facility-wide audit of care plans was underway but incomplete. The failure to revise care plans as required by facility policy and federal regulations led to deficiencies in the provision of person-centered care and fall prevention for residents at risk.
Sanitation and Temperature Control Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in the kitchen. Observations revealed that kitchen staff did not handle ready-to-eat foods appropriately to prevent cross-contamination. Specifically, a cook used the same pair of gloves to handle hamburger buns, tray cards, and serving utensils without changing gloves or washing hands. Another cook was observed touching hamburger buns and serving utensils with the same pair of gloves. The dietary director confirmed that ready-to-eat foods should be handled with tongs and that gloves should be changed between tasks. The facility also failed to maintain safe holding temperatures for food items. During lunch service, a batch of french fries was served at 125 degrees Fahrenheit, below the safe temperature of 135 degrees Fahrenheit. Additionally, MedPass nutritional supplements stored on medication carts were found at temperatures above the safe range for cold foods, with one measuring 58 degrees Fahrenheit and another 62 degrees Fahrenheit. The kitchen temperature log book had not been updated for the lunch service on the day of the survey. Interviews with kitchen staff and the dietary director revealed a lack of adherence to proper food handling and temperature control guidelines. Despite previous education on these topics, staff continued to serve food at unsafe temperatures and failed to maintain temperature logs. The dietary director was unaware of the kitchen's involvement in supplement storage on medication carts and did not know the required storage temperature for the nutritional supplements.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored and labeled on three of five units, as observed during a survey. Specifically, topical medications for residents were not stored in locked medication carts or storage rooms accessible only to authorized licensed personnel. The facility's policy, reviewed in February 2023, mandates that compartments containing medications must be locked when not in use, and medications should be stored in an orderly manner to prevent mixing. However, observations revealed that medications were left unsecured in various locations, including shower rooms and residents' rooms. During the survey, it was noted that a cart in the E hallway shower room contained a cream labeled for a specific resident and an unlabeled over-the-counter antifungal spray. Similar unsecured medications were found in other areas, including a resident's room and other hallway shower rooms. Interviews with staff, including a registered nurse and the director of nursing, confirmed that medications should be secured and not accessible to unlicensed personnel. The unsecured medications posed a risk of unauthorized access and potential self-administration by residents.
Infection Control Deficiencies in Housekeeping and Personal Care Management
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies observed across four of five units. Housekeeping staff did not adhere to proper cleaning protocols, resulting in unsanitary conditions. Specifically, a housekeeper was observed cleaning resident rooms and bathrooms without following the correct sequence of cleaning from clean to dirty areas. The housekeeper also failed to maintain the required disinfectant contact time on surfaces and did not perform hand hygiene or change gloves appropriately between tasks. Additionally, the toilet brush was improperly handled, contributing to potential contamination. Personal care items were not managed in a sanitary manner, as observed in the facility's shower rooms. Various personal care products, such as creams, lotions, shampoos, and deodorants, were found unlabeled and stored in a manner that could lead to cross-contamination among residents. Staff interviews confirmed that personal items should be labeled and stored individually to prevent use on multiple residents, but this practice was not consistently followed. The facility also failed to maintain a urinary catheter in a sanitary manner for a resident. The resident's urinary catheter drainage bag was repeatedly observed on the floor or hanging on the edge of a trash can, which could lead to contamination. Staff interviews revealed that the drainage bag's hook was broken, and the bag should have been replaced to prevent it from being placed on the floor. These deficiencies highlight significant lapses in infection control practices within the facility.
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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 Mancos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Grande Rehabilitation And Healthcare Center | 20.3 mi | — | 0 | 0 |
| Durango Health And Rehabilitation | 22.8 mi | — | 2 | 0 |
| Cottonwood Rehabilitation And Healthcare Center | 25.3 mi | — | 1 | 0 |
| Aztec Healthcare | 38.7 mi | — | 5 | 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.