Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Valley View Care Center during CMS and state inspections, most recent first.
A resident with a history of traumatic brain injury, psychotic disorder, alcohol dependence, and moderate cognitive impairment eloped from the facility despite being identified as an elopement risk and having interventions in place. The resident was able to climb over the perimeter fence using tension wires as footholds, and the incident was not captured by security cameras due to a blind spot. Staff were conducting 15-minute checks, but the resident was found missing during routine rounds and was later located off facility grounds.
Multiple residents with cognitive and behavioral impairments engaged in physical altercations, resulting in pain and distress for those involved. Despite having care plans and staff training in place, the lack of consistent hallway monitoring and immediate intervention allowed these incidents to occur, with staff often responding only after altercations had already taken place.
A resident with dementia and schizophrenia eloped from a facility specializing in severe mental illness care due to inadequate supervision and security measures. The resident exploited weaknesses in the facility's fencing and was unnoticed for 16 hours. Staff had stopped conducting regular checks, and the resident's care plan was not followed, leading to the elopement.
The facility did not conduct a comprehensive assessment to determine necessary resources for resident care in a secured locked environment. The assessment lacked details on supplies, equipment, and care needs, as well as staff training for residents with mental illness and dementia. The NHA could not recall specific details about the needs of residents in a secure facility.
The facility did not have a written transfer agreement with a local hospital certified by Medicare or Medicaid, which is essential for ensuring timely transfer and admission of residents needing hospital care. The NHA confirmed the absence of such an agreement and recognized its importance.
The facility failed to maintain a sanitary and comfortable environment, with broken and dusty window blinds in several resident rooms and the dining room, and damaged heating units and ceiling in common areas. A resident expressed discomfort due to the dusty blinds. The NHA acknowledged the absence of a permanent maintenance director and the need for repairs and routine cleaning.
The facility failed to protect residents from abuse, with multiple incidents involving physical and verbal abuse by other residents and a staff member. Despite substantiating these incidents, the facility did not update care plans or implement new interventions to prevent future occurrences, indicating a systemic issue in addressing resident abuse.
A facility failed to provide a resident with quarterly personal funds statements, as required. The resident, who was cognitively intact, reported not receiving a statement since June 2024. Interviews revealed inconsistencies in the process, with the BOM unable to confirm the last issuance and the NHA unaware of the quarterly requirement. The facility lacked documentation to prove compliance.
The facility failed to provide timely meal services, causing residents to wait for extended periods and impacting their dignity and respect. Observations and interviews revealed consistent delays in lunch service, with residents expressing frustration and boredom. Staff attributed the issue to the cook's tardiness and the dining room's small size, despite previous efforts to address the problem.
The facility failed to maintain sanitary kitchen conditions and proper food storage. The walk-in refrigerator did not maintain a safe temperature, and food items were found at temperatures above 52°F. Additionally, the kitchen had broken floor and wall tiles, a sagging ceiling, and had not been deep cleaned for several months. Staff interviews confirmed the issues, and despite notifying administration, repairs were not made due to budget constraints.
The facility failed to maintain kitchen equipment in safe operating condition, with a broken oven and two non-functional burners. Staff reported the issues had persisted for over a year due to budget constraints, leading to inefficient cooking and delayed meal service.
The facility failed to ensure that a resident received baths according to his preferred schedule and type, thereby not honoring his right to self-determination. The resident missed six out of 17 scheduled baths on his preferred days and received a bed bath once instead of a tub bath. Staff interviews revealed issues with weekend staffing and misunderstandings about responsibilities.
The facility failed to incorporate PASRR Level II recommendations into the care plan and transition of care for a resident with severe cognitive impairments and a history of inappropriate social behavior. The resident did not receive the recommended psychotherapy services, and staff did not follow the PASRR guidelines for managing the resident's behavior.
A resident did not receive timely dental care, specifically dentures, despite being edentulous and having a physician's order for dental services. The facility's staff were unaware or did not act on the resident's dental needs, leading to prolonged discomfort and difficulty eating.
Failure to Prevent Elopement for Resident with Cognitive Impairment and Behavioral Health Needs
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for one of three residents identified as being at risk for elopement. The resident in question had a history of traumatic brain injury, psychotic disorder with delusions, alcohol dependence with alcohol-induced dementia, and moderate cognitive impairment, as evidenced by a BIMS score of eight out of 15. The resident was independent in activities of daily living and had a documented pattern of wandering and exit-seeking behaviors, including a history of elopement from other facilities. The care plan identified the resident as an elopement risk and included interventions such as secure unit placement, monitoring, and redirection from exits. Despite these interventions, the resident was able to elope from the facility. On the evening of the incident, the resident was last seen during routine building rounds and was later found missing during the next round. Facility staff initiated a search and notified appropriate parties, including the DON, NHA, physician, and local police. The resident was located off facility grounds by staff, noted to have a strong odor of alcohol, and returned to the facility. Interviews and documentation revealed that the resident was able to climb over the perimeter fence by using tension wires as footholds, exploiting a physical vulnerability in the facility's security measures. The facility's security cameras did not capture the elopement due to a blind spot. Staff interviews confirmed that the resident had previously expressed a desire to leave the facility, particularly after interactions with family members, and that the facility was conducting 15-minute checks on residents. The resident's agitation increased after a phone call with his mother on the day of the elopement. The facility's elopement and wandering policy required assessments and individualized care planning for residents at risk, but the measures in place were insufficient to prevent the resident from leaving the premises unsupervised.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, neglect, and exploitation, as evidenced by several substantiated incidents of resident-to-resident altercations. In at least six cases, residents with known histories of behavioral disturbances, cognitive impairment, or impulse control issues physically assaulted other residents. These incidents occurred in common areas such as hallways, often when staff were not present to monitor or intervene. In some cases, video surveillance captured the altercations, and staff responded after the fact, but the lack of immediate supervision allowed the incidents to occur. Residents involved in these altercations had documented behavioral care plans identifying their potential for aggression and specific triggers, such as invasion of personal space, waiting for meals, or agitation when others entered their rooms. Despite these care plans, interventions were not always sufficient to prevent physical altercations. For example, one resident with dementia and behavioral disturbances struck another resident after a perceived invasion of personal space, while another resident with a history of aggression hit a peer in the hallway after being followed too closely. In several cases, the victims experienced pain or distress, and in one instance, a resident fell and required X-rays to rule out fractures. Staff interviews revealed that hallways were not consistently monitored, especially when CNAs were providing care in resident rooms or on breaks. Although the facility had video surveillance, it was not continuously monitored, and staff relied on periodic checks or responded to incidents after they occurred. Staff were aware of residents with aggressive behaviors and had received training in abuse prevention and de-escalation, but the lack of consistent supervision and immediate intervention contributed to the failure to prevent resident-to-resident abuse.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with dementia and schizophrenia. The resident, who had a history of elopement and decisional incapacity, managed to leave the facility unnoticed for approximately 16 hours. The facility, which specializes in serving residents with severe mental illness and behavioral health issues, did not conduct regular checks to ensure residents' presence, despite the known risk of elopement-seeking behavior among its residents. The resident was able to elope by exploiting weaknesses in the facility's security measures. Video footage revealed that the resident unscrewed yard lights and tampered with the fence, eventually climbing over it. The facility's security fencing lacked adequate monitoring, and staff were preoccupied with an unrelated incident at the time of the resident's escape. The resident's absence was not noticed until the following day when staff were gathering residents for lunch. Interviews and record reviews indicated that staff had ceased conducting regular checks on residents and the security fencing. The resident's care plan, which included monitoring for exit-seeking behavior, was not followed, and staff failed to notice the resident's activities at the fence. The facility's failure to maintain adequate supervision and security measures allowed the resident to leave the facility unsupervised, posing a serious risk to the resident's safety.
Failure to Conduct Comprehensive Facility Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment necessary to care for residents competently during both day-to-day operations and emergencies. The assessment did not include a detailed review of the supplies, equipment, and care needed for operating a totally secured locked facility, nor did it consider the specific care requirements of the resident population. This includes using evidence-based, data-driven methods to assess the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, and overall acuity present within the resident population. Additionally, the facility assessment lacked documentation of the staff training and education necessary to provide the level and types of support and care required for residents in a secured locked environment. The nursing home administrator (NHA) acknowledged that the facility assessment was recently updated but could not recall specific details regarding the needs of residents in a secure facility. This deficiency was cross-referenced with a failure to prevent a resident from eloping a secured locked facility, indicating a significant oversight in the facility's assessment and planning processes.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with at least one local hospital certified by Medicare or Medicaid, which is necessary to ensure the timely transfer and admission of residents requiring hospital care. During a record review, the facility was unable to provide documentation of such an agreement with a local area hospital. In an interview, the Nursing Home Administrator (NHA) confirmed the absence of a current transfer agreement and acknowledged the importance of having one in place to facilitate the transfer of residents when medically necessary.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in several resident rooms and common areas. Specifically, seven resident rooms had broken window blinds that were yellow and heavily soiled with dust and debris. Additionally, the window blinds in the dining room were also broken and dusty. The heating units outside of two resident rooms were bent and coming off the wall, and there was a broken doorframe in one of the rooms. Furthermore, a ceiling in the hallway had a three-inch hole and a cracked heating cooling vent. During interviews, a resident expressed that the dusty blinds in their room were bothersome and had been an issue for some time. The Nursing Home Administrator (NHA) acknowledged the facility's lack of a permanent maintenance director and mentioned plans to promote a current staff member to the position. The NHA also recognized the need to inspect the broken blinds and other areas requiring repair, and noted that the blinds should be on a routine cleaning schedule.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, both physical and verbal, by other residents and a staff member. Resident #1 was involved in two separate incidents of physical abuse. In the first incident, Resident #1 entered Resident #6's room and was physically assaulted. Despite the incident being substantiated, no new interventions were added to Resident #1's care plan. In a second incident, Resident #1 was attacked by Resident #2 in the hallway, with video footage confirming the assault. Again, no updates were made to Resident #1's care plan following this incident. Resident #7 was also a victim of physical abuse by Resident #2, who kicked Resident #7 in the leg. The facility substantiated this abuse, but the report does not indicate any changes to Resident #7's care plan. Similarly, Resident #4 was pushed by Resident #5, causing a fall, and Resident #10 was struck by Resident #11. Both incidents were substantiated, yet there is no mention of care plan updates or additional interventions to prevent future occurrences. Additionally, Resident #3 experienced verbal abuse from a staff member, LPN #1, during a confrontation over a styrofoam cup. The altercation escalated to yelling, with LPN #1 challenging Resident #3 to hit her. This incident was also substantiated, highlighting a failure in staff conduct and resident protection. The facility's policy emphasizes the importance of preventing abuse, yet the repeated incidents and lack of care plan updates suggest a systemic issue in addressing and mitigating resident abuse.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to establish and maintain a system that ensures a full and complete separate accounting of each resident's personal funds, as required by generally accepted accounting principles. This deficiency was identified for one resident out of four reviewed for personal funds management. Specifically, the facility did not provide the resident with a copy of her personal funds statement on at least a quarterly basis, as required. The resident, who was cognitively intact and required no assistance with activities of daily living, reported not receiving a personal funds statement since June 2024, despite the expectation of receiving it every three months. Interviews with the business office manager (BOM) and the nursing home administrator (NHA) revealed a lack of clarity and consistency in the process of distributing personal funds statements. The BOM claimed that statements were sent out monthly, but could not confirm when the resident last received one. The NHA was unaware of the quarterly requirement and indicated that the corporate office was responsible for managing resident funds and distributing statements. The facility was unable to provide documentation to show that the resident had received her quarterly statements, highlighting a breakdown in communication and procedure regarding the management of resident personal funds.
Delayed Meal Service Affects Resident Dignity
Penalty
Summary
The facility failed to provide meal services in a timely manner, which affected the dignity and respect of residents in two dining rooms. The posted meal times were not adhered to, resulting in residents waiting for extended periods before being served. Observations revealed that lunch service was consistently late, with the first resident being served lunch one hour and 16 minutes late on one occasion and one hour and 39 minutes late on another. Residents expressed frustration and boredom while waiting, with some falling asleep or having to leave the dining room to use the bathroom, only to return to cold meals. Additionally, there were issues with seating availability and broken tables, further complicating the dining experience for residents. Interviews with staff confirmed the delays in meal service, attributing the issue to the cook's tardiness and the need for additional training on timeliness. The nutrition services manager acknowledged the problem and mentioned that the dining room's small size contributed to the delays, as staff had to serve and clean up sequentially. The nursing home administrator also recognized the issue, stating that late meals were unacceptable and that the cook had been educated multiple times on the importance of timely meal service. Despite these efforts, the deficiency persisted, impacting the residents' dining experience and overall well-being.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to ensure food was prepared, distributed, and served under sanitary conditions in the kitchen. Specifically, the walk-in refrigerator did not maintain a safe operating temperature of 41 degrees Fahrenheit or below, as observed when the thermometer indicated an internal temperature of 45 degrees Fahrenheit. Two cooling fans were non-functional, and food items such as a fruit cup and yogurt were measured at temperatures above 52 degrees Fahrenheit. The temperature log was incomplete, and some entries were missing, making it impossible to determine how long the issue had been present. Staff interviews confirmed the importance of maintaining proper temperatures to prevent foodborne illnesses, but the logs were not consistently maintained, and the refrigerator's malfunction was not promptly addressed. Additionally, the facility failed to ensure all surfaces in the kitchen were cleanable. Observations revealed approximately 15 broken floor tiles, a missing tile by the dishwasher, broken wall tiles in the dry storage room, and a sagging, visibly dirty ceiling with brown and grease stains. Staff interviews indicated that the kitchen had not been deep cleaned for several months, and the broken tiles posed both an infection control issue and a slip and trip hazard. Despite notifying administration and obtaining quotes for repairs, the necessary maintenance was not performed due to budget constraints. The nursing home administrator and infection preventionist acknowledged the unsanitary conditions and the potential health risks posed by the broken tiles and malfunctioning refrigerator. The administrator confirmed that the corporation had refused to approve the necessary repairs due to cost, and the kitchen staff lacked motivation to maintain cleanliness in the deteriorating environment. The infection preventionist emphasized the need for routine cleaning and repairs to prevent microorganism growth and ensure a safe working environment.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the main kitchen. Specifically, the kitchen's oven was not maintained to function properly, two of six burners were not functioning, and the oven door was not repaired to ensure consistent and appropriate cooking temperatures. Observations revealed that the oven door had a one-inch gap and was difficult to open due to a malfunctioning latch, preventing it from closing securely. Only four of six burners were functional, which hindered efficient cooking and delayed meal service for residents. Interviews with staff indicated that the oven and stove had been broken for at least a year and a half, and despite notifying supervisors and the former facility administrator, no repairs were made due to budget constraints. The dietary aide expressed frustration over the lack of repairs, noting that the broken equipment made it difficult to complete his job and posed a safety concern. The nutrition services manager confirmed that repair requests were denied due to budget issues, leading to inconsistent cooking times and difficulties in meal preparation. The nursing home administrator acknowledged awareness of the broken equipment and the corporation's refusal to repair it due to budget constraints.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to ensure that a resident received baths according to his preferred schedule and type, thereby not honoring his right to self-determination. Resident #10, who has a history of traumatic brain injury and moderate cognitive impairment, expressed a preference for baths on Wednesdays and Saturdays. However, the facility did not consistently provide baths on these days, and on one occasion, the resident received a bed bath instead of a tub bath as he preferred. The resident's bathing logs from March to May 2024 showed that he missed six out of 17 scheduled baths on his preferred days and received a bed bath once instead of a tub bath. Interviews with staff revealed systemic issues contributing to this deficiency. CNAs reported difficulty in providing baths on weekends due to the absence of a scheduled bath aide and the high workload. Some CNAs believed that bathing was solely the bath aide's responsibility, leading to refusals to assist with baths. The DON acknowledged the issue and mentioned ongoing efforts to educate staff about their responsibilities. Despite these efforts, the facility failed to ensure that the resident's bathing preferences were consistently met, thereby violating his right to self-determination and choice.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into the assessment, care planning, and transition of care for a resident. Specifically, the facility did not take steps to ensure services were provided as recommended in the PASRR Level II report and did not include these recommendations in the resident's care plan. The resident, who had severe cognitive impairments and a history of inappropriate social behavior and physical aggression, was not provided with the necessary psychotherapy services as outlined in the PASRR Level II report. The resident's PASRR Level II report, dated several years prior, indicated that the resident exhibited inappropriate social behavior and physical aggression, including sexually inappropriate actions towards staff and peers. The report recommended that staff calmly redirect the resident with clear and simple directions and observe environmental triggers for the behavior. Additionally, the report recommended that the resident receive individual therapy twice monthly from a qualified community mental health professional. However, a review of the resident's comprehensive care plan and social services progress notes revealed that these recommendations were not followed. Interviews with facility staff confirmed that the PASRR recommendations were not implemented. The Social Services Director (SSD) acknowledged that the resident had not received the recommended psychotherapy services and that the facility had not conducted a whole-house audit to identify residents with Level II PASRRs. The SSD stated that the facility would audit all residents' PASRRs and ensure all recommendations were followed, but at the time of the review, these actions had not been completed.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure that Resident #23 received timely dental care, specifically the provision of dentures. Despite being edentulous and having a physician's order for dental services, the resident had not been referred to a dentist since his admission in January 2024. The resident expressed difficulty eating and had been consuming mainly grilled cheese sandwiches due to the lack of dentures. The facility's records and interviews with staff confirmed that the resident's dental needs were not addressed in his care plan, and no dental services were provided during his stay at the facility. The facility's Ancillary Service policy mandates that residents receive necessary ancillary services, including dental care, in a timely manner. However, the facility did not adhere to this policy for Resident #23. The Social Service Director (SSD) acknowledged that the facility's previous dentist stopped visiting in December 2023 and ceased accepting Medicaid in March 2024. Although a new dentist was contracted, no date was set for the initial visit, and the resident was not referred to a community dentist in the interim. Interviews with the Director of Nursing (DON), Licensed Practical Nurse (LPN), and Certified Nurse Aide (CNA) revealed a lack of awareness and communication regarding Resident #23's dental needs. The DON was unaware of the resident's missing dentures, and the LPN did not know about any dental concerns. The CNA was aware of the resident's edentulous state but did not take further action. This lack of coordination and timely intervention led to the resident's prolonged discomfort and difficulty in eating due to the absence of dentures.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canon City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canon Lodge Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Skyline Ridge Nursing & Rehabilitation Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Hildebrand Care Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Progressive Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Bruce Mccandless Co State Veterans Nursing Home | 8.9 mi | ★★★★★ | 5 | 1 |
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