Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand River Health Care Center during CMS and state inspections, most recent first.
Failure to Follow Swallowing Precautions During Meals: A resident with dysphagia, dementia, and Parkinson’s disease had repeated choking episodes and was ordered to have supervised dining with chin tuck, small bites, slow pacing, and straw use. During an observed meal, staff served a sippy cup instead of a regular cup with a straw, did not remain with the resident, and did not consistently cue safe swallowing behaviors while the resident tilted his head back and coughed/choked.
Failure to Complete Annual CNA Performance Reviews: The facility did not complete annual performance reviews for multiple CNAs and could not produce documentation showing that each CNA received a performance review at least once every 12 months. The DON stated she did not complete individual performance reviews with each CNA, and the facility did not have an applicable policy for annual evaluations. Staff education was provided through HealthStream modules and in-person in-services, but the required annual review process was not followed.
A resident with COPD, MDD, chronic respiratory failure, and CKD, who was cognitively intact with a BIMS of 15/15, requested a copy of the facility’s room change/move policy after losing her resident rights copy. Staff told her the policy would not be provided and that she could ask the NHA questions instead; the NHA confirmed the facility would not give residents copies of policies.
Missed Warfarin Dose and Inaccurate MAR Documentation: A resident receiving warfarin for a history of thrombosis and embolism had a missed 5 mg dose that was later found in the resident’s bed, while the MAR still showed the dose as given. The Coumadin RN documented a low INR after the missed dose, and interviews showed staff did not know why the dose was missed or why the documentation remained inaccurate.
Infection control failed when an RN performed wound care for a resident with a wound without wearing a protective gown for EBP and brought another resident’s wound care supplies into the bathroom during the procedure. The RN opened the supplies before finishing peri care, then completed brief change, peri care, hand hygiene, and glove change before continuing wound care. The ADON/IP said the other resident’s supplies should not have been brought into the room or bathroom, and the RN said she forgot they were on the table.
Failure to Follow Swallowing Precautions During Meals
Penalty
Summary
The facility failed to ensure swallowing precautions were consistently implemented for a resident with dysphagia, neurocognitive disorder with Lewy bodies, Parkinson’s disease, and dementia. The resident was identified as being at risk for choking on admission and had a care plan directing supervised meal assistance, upright positioning, small bites, slow eating, single sips with a straw, and food cut into small pieces with minced and moist meat. The resident also had repeated choking or near-choking episodes documented over several months, including episodes during meals and after drinking liquids. After a choking episode in which the resident expelled chunks of food and liquid, later episodes continued to occur when he drank water, drank from a dixie cup, drank hot cocoa, and during a meal when he was choking and vomiting some of his beverage. Speech therapy notes and nursing documentation repeatedly identified the need for supervision during meals, chin tuck with liquids, straw use, small sips, slow pace, and monitoring in the dining room. A physician’s order later directed that the resident be supervised at all times for eating, sit at a table where a CNA was present, and not be served until staff was present. During a breakfast observation, the resident was served a beverage in a sippy cup with a straw instead of a regular cup with a straw. He tilted his head back to drink from the spout, began coughing and choking, and staff were not sitting with him when the episode occurred. Throughout the meal, staff were not consistently present in the dining room, and the resident was not consistently cued to tuck his chin, take small bites, slow his pace, or take small sips with a straw. Interviews confirmed that staff understood the resident needed close supervision and that a sippy cup should not have been used, but the observed meal showed those precautions were not in place.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete a performance review of every CNA at least once every 12 months and did not provide regular in-service education based on the outcome of those reviews. During record review and interviews, the facility was unable to provide annual performance review documentation for CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8 before survey exit. The NHA stated he could not produce records of annual performance evaluations for those CNAs and believed the facility did not complete annual performance evaluations. The facility also did not have an applicable policy and procedure for annual performance evaluations. When asked for the policy, the NHA and DON could not provide one, and the ADON stated the facility did not have one. During interview, the DON said she did not complete an individual performance review with each CNA in the facility. She stated staff completed HealthStream education modules and in-person in-service education, and that leadership met monthly to discuss education topics for all staff and any events requiring education for individual staff members. She also said that when an individual staff member received education, the facility typically gave the same education to all staff in the next in-service training.
Failure to Provide Resident Rights and Requested Policy
Penalty
Summary
The facility failed to provide ongoing communication to residents about their rights and failed to inform a resident both orally and in writing, in a language the resident understands, of the resident’s rights and all rules and regulations governing resident conduct and responsibilities during the stay. The deficiency involved Resident #50, who was admitted with diagnoses including COPD, major depressive disorder, chronic respiratory failure, and chronic kidney disease. Her 12/19/25 MDS showed she was cognitively intact with a BIMS score of 15 out of 15, and she was largely independent with mobility and self-care, using a motorized wheelchair. Resident #50 told surveyors she requested a copy of the facility’s room change/move policy after losing her resident rights copy. She said the SSD initially provided the resident rights, but when she asked for the room change/move policy, staff told her she could not be given a copy and should speak with the NHA if she had questions. The SSD confirmed she asked the NHA for the policy and was told it did not have to be provided to the resident. The NHA confirmed the facility would not provide Resident #50 a copy of the requested room change/move policy, stating the compliance and legal team were not comfortable giving residents copies of policies.
Missed Warfarin Dose and Inaccurate MAR Documentation
Penalty
Summary
The facility failed to ensure that a resident receiving warfarin was free from a significant medication error. Resident #10 had diagnoses including a history of venous thrombosis and embolism, epilepsy, and chronic obstructive pulmonary disease, and was cognitively intact with a BIMS score of 14 out of 15. The resident’s care plan identified the need to maintain INR levels in the therapeutic range and included interventions for Coumadin administration, lab monitoring, and monitoring for complications. The resident had physician orders for warfarin 2 mg on Monday, Wednesday, Thursday, and Saturday, and warfarin 5 mg on Sunday, Tuesday, and Friday at 8:00 p.m. The January 2026 MAR documented that all warfarin doses were administered, but progress notes showed that the resident did not receive the 5 mg warfarin dose on 1/9/26. A progress note on 1/10/26 documented that the 5 mg tablet was found in the resident’s bed the next morning. The Coumadin clinic RN later documented that the resident’s INR was low because the 5 mg dose had been missed, and the resident’s INR was 1.3 on 1/13/26. Interviews showed that staff were aware the dose had been missed, but the reason for the missed dose was not known. The Coumadin clinic RN stated she did not know why the medication was missed or why the MAR continued to show it as given. The DON and ADON stated they were not aware of the missed dose at the time it occurred, and the ADON said he was not sure why the medication was marked as administered on the MAR. The ADON also stated that the investigation of the medication error had not yet been completed at the time of interview.
Infection Control Failure During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when RN #3 performed wound care for Resident #33 without following enhanced barrier precautions and while wound care supplies for another resident were present in the same care area. During the wound care encounter, RN #3 rolled a metal table into Resident #33’s bathroom and opened wound care supplies while the resident was using the bathroom. A plastic basket containing wound care supplies for Resident #3 was also on the lower level of the table during this time. After Resident #33 finished using the bathroom, RN #3 changed the resident’s brief, completed peri care, cleaned stool from the toilet seat, performed hand hygiene, and changed gloves before proceeding with wound care. However, all of the wound care supplies had already been opened before peri care was completed. RN #3 also did not wear a protective gown during the wound care for Resident #33. The report states that Resident #33 had a wound treated with alginate and a dressing, and the ADON later described the wound as an abrasion that had stalled in healing for 2 weeks. RN #3 stated she normally did not bring the wound care table into the bathroom, but did so because Resident #33 wanted to use the bathroom and did not want to lie in bed during wound care. She said she forgot that Resident #3’s wound care supplies were on the bottom of the table when she entered Resident #33’s bathroom and forgot to remove them when she switched to complete Resident #33’s wound care first. The ADON, who also served as the infection preventionist, stated RN #3 should not have taken Resident #3’s wound care supplies into Resident #33’s room or bathroom and acknowledged there was still risk of contamination of those supplies. The ADON also stated Resident #33 was not on EBP because he interpreted the wound as not meeting CDC criteria.
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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 Rifle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colorado State Veterans Nursing Home - Rifle | 0.5 mi | ★★★★★ | 2 | 0 |
| Glenwood Springs Healthcare | 24.5 mi | ★★★★★ | 3 | 0 |
| Heritage Park Care Center | 31.1 mi | ★★★★★ | 0 | 0 |
| Walbridge Memorial Convalescent Wing | 36.5 mi | ★★★★★ | 17 | 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.