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 Yampa Valley Healthcare Center during CMS and state inspections, most recent first.
Three residents were not adequately protected from accidents or hazards due to the facility's failure to implement and maintain appropriate interventions. One resident with dementia and a history of wandering eloped from the facility without updated care plan interventions or consistent use of a wanderguard. Another resident with multiple comorbidities and a high fall risk experienced repeated falls, with incomplete documentation of oxygen use and vital signs. A third resident with Huntington's disease did not consistently receive staff escort or visual reminders to call for assistance, and care plan interventions were not maintained after a fall.
A resident with multiple medical conditions eloped from the facility and was later found with altered mental status. After the incident, staff applied a wanderguard bracelet but failed to obtain a physician's order, did not update the care plan, and did not complete a new wander risk assessment as required by facility policy. Staff interviews confirmed these omissions, and the DON acknowledged the lack of necessary documentation and updates.
The facility did not adequately promote or facilitate a resident's right to self-determination by failing to support resident choice, as required by regulation.
Two residents experienced severe weight loss due to the facility's failure to implement effective nutritional interventions. One resident lost 22 pounds over six months, and another lost 24 pounds over three months. The facility did not obtain necessary physician orders for supplements, failed to track residents' acceptance of interventions, and did not adequately address food preferences. Staff interviews revealed challenges in encouraging residents to eat and a lack of a full-time dietary manager.
The facility failed to employ a qualified dietary manager (DM) or have a full-time registered dietitian (RD). Observations and interviews revealed the absence of a DM, with the RD only available on a consultant basis. The nursing home administrator confirmed the position was advertised but had no applicants, and the last DM left over a month ago.
Housekeeping staff at the facility failed to follow proper infection control procedures, using non-approved cleaning products and not changing mop heads or performing hand hygiene between cleaning tasks. Observations showed improper use of disinfectants and inadequate training of staff, leading to potential infection risks.
The facility failed to properly secure controlled medications, specifically two vials of liquid Ativan, which were stored in an unlocked plastic container inside the medication refrigerator. Staff interviews revealed a lack of awareness and adherence to the facility's policy requiring controlled substances to be stored in a permanently affixed locked compartment.
A resident with Alzheimer's disease and a tendency to wander was involved in two altercations with other residents, resulting in injury and inadequate protection from abuse. Despite being placed on 15-minute safety checks, the facility failed to implement effective interventions to prevent the resident from wandering into other rooms. Observations and interviews revealed deficiencies in supervision and communication, contributing to the ongoing risk of altercations.
Failure to Prevent Accidents and Implement Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. One resident with a history of dementia, stroke, and wandering behaviors experienced an elopement event, leaving the facility unsupervised and traveling several blocks to a representative's workplace. Despite this incident and a subsequent assessment identifying the resident as high risk for elopement, the care plan was not updated to include interventions to prevent recurrence, and the resident's wanderguard was discontinued based on a verbal agreement rather than documented risk mitigation. Staff interviews revealed inconsistent awareness and implementation of elopement precautions, and the resident was observed without a wanderguard or clear supervision protocols in place. Another resident, admitted with end-stage heart failure, schizophrenia, and a history of falls, was identified as a high fall risk but did not receive consistent fall prevention interventions. The resident experienced multiple falls during their stay, including one incident where they pulled out a Foley catheter and slipped in urine, and another unwitnessed fall found by a representative. Documentation failed to consistently record whether the resident was using supplemental oxygen at the time of falls, and vital signs, including oxygen saturation, were not always documented after incidents. The care plan included general fall prevention strategies but lacked specific interventions tailored to the resident's needs and did not reflect the use of supplemental oxygen, despite its clinical relevance. A third resident with Huntington's disease and a history of falls was not consistently provided with care plan interventions such as staff escort to and from meals and visual reminders to call for assistance before transferring. Observations showed the resident self-transferring without staff assistance or using the call light, and the required reminder sign was missing from the room after a recent move. There was no evidence that the care plan was reviewed or updated following a recent fall, and staff interviews confirmed lapses in implementing and maintaining fall prevention measures.
Failure to Assess, Document, and Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who experienced an elopement event. After the resident, who had multiple diagnoses including diabetes type I, epilepsy, Parkinson's disease, and a history of central nervous system infection, left the facility without staff knowledge, the facility did not complete a new wander risk assessment to address the change in the resident's condition. The resident was found by an LPN outside the facility, exhibiting altered mental status, and was subsequently transported to the hospital for evaluation. Following the elopement, the facility applied a wanderguard bracelet to the resident; however, there was no documentation of a physician's order for the use of the wanderguard or for monitoring its function. Additionally, the resident's care plan was not updated to reflect the use of the wanderguard or to address the increased risk for wandering or elopement after the incident. The electronic medical record did not contain an assessment for the use of the wanderguard prior to its implementation, nor did it include documentation related to the change of condition on the day of the elopement. Staff interviews confirmed that a physician's order should have been obtained for the wanderguard and that the care plan and risk assessment should have been updated following the event. The DON acknowledged the lack of these updates and documentation. The facility's own policy required identification of residents at risk for wandering and updating care plans with appropriate interventions, which was not followed in this case.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulation.
Failure to Address Nutritional Needs Leads to Severe Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutritional care for two residents, leading to significant weight loss. Resident #26, admitted with conditions including dementia and depression, experienced a severe weight loss of 22 pounds over six months. Despite recommendations from the registered dietitian (RD) to implement a house nutrition supplement, the facility did not obtain a physician's order for the supplement or track the resident's acceptance of it. Observations showed that staff did not encourage the resident to eat more or offer additional food, and the care plan lacked new person-centered nutritional interventions after the resident's significant weight loss. Resident #5, diagnosed with conditions such as COPD and diabetes, also experienced severe weight loss, losing 24 pounds over three months. The facility's interventions were insufficient, as the resident's food preferences were not adequately addressed, and there was no documentation of the resident's significant weight loss in the physician's progress notes. The resident expressed dissatisfaction with the food served and was unaware of alternative meal options, indicating a lack of effective communication and person-centered care. The facility's policy required immediate notification of the dietitian for significant weight changes, but this was not effectively implemented. Staff interviews revealed challenges in encouraging residents to eat and a lack of a full-time dietary manager, which contributed to the deficiencies. The RD noted that residents' preferences and interventions were not included in care plans, and there was a lack of detailed documentation regarding residents' nutritional status and weight loss.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, as required. Observations during a kitchen tour revealed the absence of a dietary manager (DM) employed at the facility. Record reviews confirmed the lack of documentation indicating the employment of a qualified DM. Interviews with the nursing home administrator (NHA) and staff further corroborated this deficiency. The NHA acknowledged the absence of a DM and mentioned that the position was advertised but had not yet attracted any candidates. The registered dietitian (RD) was only available on a consultant basis, visiting the facility twice a month, and was not employed full or part-time. The cook and dietary aide confirmed that the last DM had left over a month ago, leaving the facility without a qualified DM.
Inadequate Infection Control Practices by Housekeeping Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper cleaning procedures followed by housekeeping staff. Observations revealed that housekeeping staff did not adhere to proper infection control protocols while cleaning resident rooms. Specifically, a housekeeper used the same mop head and mop water to clean multiple rooms, including resident rooms, a living room, and a dining room, without changing them between areas. Additionally, the cleaning product used, Fabuloso Original Orange with Baking Soda, was not approved for disinfection purposes in healthcare settings. Further observations showed that the housekeeper did not perform hand hygiene before putting on gloves and entering a resident's room. The housekeeper also failed to allow the Virex II 256 disinfectant to remain wet on surfaces for the manufacturer's recommended time, and used the same rag to clean both the bathroom and the resident's dressers without changing gloves or performing hand hygiene. The housekeeper did not spray disinfectant on the dressers or other surfaces in the resident's room, and did not change gloves or perform hand hygiene before returning to the room to clean additional surfaces. Interviews with the housekeeping staff revealed a lack of proper training and understanding of infection control procedures. One housekeeper had only been in the position for a short time and was trained by another housekeeper who had not received formal training. The nursing home administrator acknowledged that the housekeepers should change mop pads and cleaning rags between different areas to prevent the spread of germs. The clinical nurse consultant emphasized the importance of following specific cleaning instructions to avoid spreading infections.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored in accordance with accepted professional standards. During an observation, it was noted that two vials of liquid Ativan, a Schedule IV controlled substance, were stored in a plastic container on a shelf inside the medication refrigerator. These vials were not secured in a permanently affixed locked compartment, which is a requirement for controlled substances to prevent unauthorized access. Interviews with staff revealed a lack of awareness and adherence to the facility's policy regarding the storage of controlled medications. An LPN acknowledged that the Ativan was accessible to anyone with access to the refrigerator, as it was not locked in a separate compartment. The clinical nurse consultant confirmed that controlled medications should be double-locked to prevent unauthorized access. The director of nursing was unaware of the requirement for a permanently affixed locked container inside the refrigerator, indicating a gap in knowledge and implementation of the facility's medication storage policy.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving three residents. Resident #1, diagnosed with Alzheimer's disease and a tendency to wander, was involved in two separate altercations with other residents. On February 28, 2024, Resident #1 wandered into Resident #2's room and refused to leave, resulting in Resident #2 pushing Resident #1 to the floor. This incident led to Resident #1 sustaining a fracture to the right femoral neck, requiring hospitalization and surgical repair. Despite being placed on 15-minute safety checks upon returning to the facility, Resident #1 was involved in another altercation on July 9, 2024, when he entered Resident #3's room and refused to leave, leading to a physical confrontation. The facility's policies and procedures for abuse prevention were not effectively implemented, as evidenced by the repeated incidents involving Resident #1. The facility's investigation into the February 28 incident confirmed that Resident #1 had a history of wandering and that the altercation with Resident #2 was substantiated. However, the facility failed to implement new, effective person-centered interventions to prevent Resident #1 from wandering into other residents' rooms, resulting in the subsequent altercation with Resident #3. The facility did not substantiate the July 9 incident as abuse, despite Resident #1 hitting and pulling Resident #3's hair. Observations and interviews revealed further deficiencies in the facility's care and supervision of Resident #1. During a continuous observation on August 7, 2024, staff failed to complete 15-minute checks on Resident #1 as required. Interviews with staff, including the NHA and DON, indicated a lack of awareness and communication regarding Resident #1's care plan and supervision needs. The facility also failed to update Resident #1's care plan with new interventions following the altercations, and staff did not consistently attempt to communicate with Resident #1 in his preferred language. These failures contributed to the ongoing risk of resident-to-resident altercations and inadequate protection from abuse.
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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 Craig
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walbridge Memorial Convalescent Wing | 38.6 mi | — | 17 | 0 |
| Casey's Pond Senior Living | 39.7 mi | — | 0 | 0 |
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