Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 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.
The facility failed to designate an RN to serve as the DON on a full-time basis after the DON’s RN license expired. Survey review and interviews showed the facility was notified that the license had expired, the DON was unable to renew it right away, and the license renewal date had been monitored by the service center rather than facility staff.
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.
Improper labeling of medications in storage areas. An LPN and the ADON observed multiple medications stored in labeled boxes, but the individual bottles, pen-injectors, and ointment tube were not labeled with the resident's name or the date opened. The items included fluticasone nasal spray, Ozempic injectors, and LubriFresh P.M. ointment for several residents.
Infection Control Failures in Housekeeping and Catheter Handling: A housekeeper was observed cleaning resident rooms without disinfecting high-touch items such as call lights and remotes, changing gloves without hand hygiene, reusing a toilet brush without disinfecting it, and mopping both sides of a room together instead of separately. A resident with a urinary catheter was repeatedly observed with the catheter bag and tubing resting on the floor, and the housekeeper was seen lifting the tubing while mopping around it.
Failure to assess whether a cognitively intact resident could safely self-administer eye drops. An RN observed the resident independently give himself Brimonidine eye drops under supervision, but the EMR had no documentation of a self-administration assessment. The RN was unsure if the assessment existed, and the ADON confirmed it had not been completed before the survey.
A facility failed to provide necessary behavioral health care and services for two residents. One resident had a documented trauma history, alcohol use disorder, and worsening PHQ-9 depression scores, but the care plan did not include the trauma history or person-centered mood interventions, and the record did not show action when depression increased. Another resident with cancer, stroke-related deficits, and moderate depression expressed suicidal ideation and said he would refuse food and meds to die, but the record did not show a timely physician notification, lethality assessment, or documented behavioral health follow-up.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found a 7.69% med error rate, with two errors in 26 opportunities. An LPN gave a resident the wrong dose of pantoprazole, and an RN supervised a resident self-administering two drops of brimonidine instead of the ordered one drop. The facility policy required meds to be given as prescribed and documented appropriately when withheld, refused, or given at a different time.
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.
Expired RN License Left DON Role Without Full-Time RN Coverage
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis after the DON’s RN license expired. Record review confirmed that the DON’s RN license expired on the date identified in the report, and the deficiency was cited based on the facility’s failure to maintain an RN in the DON role on a full-time basis. During interviews, the nursing home administrator and the regional clinical resource stated the facility was notified by the facility’s service center that the DON’s RN license on file had expired. The administrator reported that the DON attempted to renew the license online and in person the following day but was unable to do so, and that the facility then designated a facility RN charge nurse as the DON. The administrator also stated that the license renewal date was monitored by the service center rather than facility staff, and the DON did not receive a reminder email to renew the license.
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.
Improper Labeling of Medications in Storage Areas
Penalty
Summary
Drugs and biologicals were not all stored and labeled in accordance with accepted professional principles. During observations, medication cart #1 on the fourth floor contained a fluticasone propionate nasal spray bottle for Resident #47 that was stored in an appropriately labeled medication box, but the individual bottle itself was not labeled with the resident's name or the date it was opened. The assistant director of nursing stated that medication bottles should be labeled inside their respective medication boxes so staff would know who the medication was intended for if the box were damaged. Additional observations found similar labeling issues in the third floor medication room and on medication cart #2. One Ozempic 2 mg/3 ml subcutaneous injector for Resident #92 and one Ozempic 4 mg/3 ml subcutaneous injector for Resident #35 were each stored in appropriately labeled medication boxes, but the individual pen-injectors were not labeled with the resident's name or the date opened. On medication cart #2, a LubriFresh P.M. ophthalmic ointment tube for Resident #95 was also stored in an appropriately labeled medication box, but the tube itself was not labeled with the resident's name or the date it was opened. LPN #4 stated that the medication bottles should be labeled inside their respective medication boxes to prevent confusion if the boxes were destroyed.
Infection Control Failures in Housekeeping and Catheter Handling
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. During observation of housekeeping activities in resident rooms, Housekeeper #1 was seen cleaning rooms #315 and #310 while not following the facility’s stated cleaning sequence and high-touch surface practices. The housekeeper sprayed disinfectant in the sink and on the toilet seat, changed gloves multiple times without performing hand hygiene between glove changes, and used microfiber rags from a disinfectant bucket to clean surfaces. High-touch items such as call lights and remotes were not disinfected during the observed cleaning of the rooms. The housekeeper also used a toilet brush from inside the resident bathroom, scrubbed the toilet bowl, and returned the brush to the bathtub or container without disinfecting it after use. The housekeeper mopped the two sides of the room together rather than separately, despite staff interviews stating that separate mop heads should be used for each side of the room and the bathroom. In a second observed cleaning of the same room, the housekeeper again cleaned the sink and toilet, used a toilet brush kept beside the toilet, and returned it without disinfecting it. The housekeeper again mopped the room in a way that mixed the two sides rather than keeping them separate. Resident #100 had a urinary catheter and was observed multiple times with the catheter bag or tubing resting on the floor or slipping onto the floor. The bag was seen on the floor in a privacy bag, folded over and touching the floor, clipped to the bed or trash can while still resting on the floor, and the tubing was also observed touching the ground. During one housekeeping observation, Housekeeper #1 mopped around the resident’s room and, with gloved hands, lifted the resident’s catheter tubing off the floor to mop underneath it, then placed the tubing back on the floor. Staff interviews stated that catheter tubing and bags should not touch the floor, that residents should be educated about sanitary catheter placement, and that housekeeping staff should not handle catheter tubing in that manner.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for one resident. The resident was admitted with diagnoses including third degree burns to both lower legs and an anxiety disorder, and the January 2026 MDS showed the resident was cognitively intact with a BIMS score of 15 out of 15. During observation, an RN prepared to administer Brimonidine tartrate ophthalmic solution eye drops, and the resident stated he was an adult and could give himself the eye drops independently. Under RN supervision, the resident self-administered two drops to the left eye. Record review showed an order for Brimonidine tartrate ophthalmic solution, one drop to the left eye twice daily for ocular hypertension, but the EMR did not contain documentation of an assessment to determine whether the resident could safely self-administer medications. During interview, the RN was unsure whether such an assessment had been completed, and the ADON stated the resident did not have a completed self-administration assessment. The ADON later stated she completed the assessment during the survey and updated the EMR, but the assessment had not been completed until that time.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents whose records showed changes in mood, trauma history, or suicidal statements. For one resident, the record showed a history of trauma related to the murder of family members, alcohol use disorder, and depression, but the comprehensive care plan did not document the trauma history or include person-centered interventions tied to the resident’s mood or behavior. Although the resident’s PHQ-9 score increased from minimal depression to moderate depression, the record did not show that the facility intervened when the depression worsened. Staff interviews confirmed that the resident’s care plan did not reflect the trauma history and that the steps taken after the worsening mood score were unclear. For the second resident, the record showed cognitive intactness, cancer, stroke-related deficits, progressive functional decline, and a PHQ-9 score indicating moderate depression. After the resident stated that he wished to end his life and said he would do so by refusing food and medications, staff placed him on 15-minute safety checks. However, the record did not show that the physician was notified at the time, did not contain a lethality assessment, and did not document social service follow-up or an offer of behavioral health services after the suicidal statement. Physician notes later focused on hospice and pain/spasticity follow-up, but did not document discussion of the suicidal ideation. Interviews with social services staff showed they understood that suicidal ideation should trigger a lethality assessment, notification of the physician and family, a safety plan, and behavioral health support, but the resident’s electronic record did not contain documentation of those actions. The record also showed that after the suicidal statement, the resident refused medications and meals on multiple occasions and later died in the facility. The deficiency was based on the facility’s failure to identify and implement person-centered behavioral health interventions for one resident and failure to coordinate timely behavioral, mental, and emotional health services for the other resident after suicidal ideation was expressed.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep its medication error rate below 5%, with surveyors identifying a 7.69% error rate, or two errors in 26 opportunities for error. The facility policy stated that medications must be administered as prescribed, may not be set up in advance, must be given within one hour before or after the scheduled time, and any withheld, refused, or late medication must be documented on the MAR. For one resident, an LPN prepared and administered pantoprazole sodium 40 mg even though the physician’s order was for Protonix 20 mg daily for heartburn. The LPN stated she checked the MAR while dispensing medications to follow the five rights, but did not realize the dose was incorrect. For another resident, an RN supervised self-administration of brimonidine tartrate ophthalmic solution and the resident independently instilled two drops in the left eye, although the order was for one drop to the left eye twice daily for ocular hypertension. The RN said she believed the order was for two drops because the resident had two eye drop medications on the MAR, and the resident’s self-administration assessment had not been completed at the time of the observation.
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 | ★★★★★ | 39 | 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 July 2026) and official state health department websites.