CANON CITY, CO - Federal inspectors cited Valley View Health Care Center for failing to prevent a resident from leaving a secured, locked facility — a violation that carries significant safety implications for residents with cognitive impairments who depend on controlled environments for their protection.
The complaint investigation, completed on February 26, 2025, also revealed the facility lacked a written hospital transfer agreement with any local hospital, meaning there was no formal arrangement in place to ensure residents could be quickly admitted for emergency medical care.
Resident Elopement From Secured Unit
The most serious finding in the inspection centered on F689, which addresses a facility's obligation to ensure residents do not leave a secured environment without authorization. Elopement from a locked unit is among the most dangerous events that can occur in a nursing home, particularly for residents with dementia, Alzheimer's disease, or other cognitive conditions.
Residents placed in secured units typically require that level of protection because they are at risk of wandering. When a resident successfully leaves a locked facility undetected, they face exposure to traffic, extreme weather, dehydration, falls, and disorientation — any of which can result in serious injury or death. Canon City's climate, with winter temperatures that can drop well below freezing in February, makes unsupervised time outdoors particularly hazardous for elderly residents.
The inspection report indicates the facility failed to maintain the systems, protocols, and oversight necessary to keep the secured environment functioning as intended.
Facility Assessment Gaps
Inspectors found that Valley View's facility assessment — last reviewed on February 14, 2025 — contained significant omissions related to operating a secured locked unit. The assessment failed to document:
- Supplies, equipment, and care protocols needed to operate a totally secured locked facility - Care requirements for the resident population using evidence-based, data-driven methods that account for diseases, conditions, physical and behavioral health needs, cognitive disabilities, and overall acuity - Staff training and education necessary to provide the level of support and care needed for residents living in a secured locked environment
Federal regulations require nursing homes to conduct comprehensive facility assessments that realistically evaluate their capacity to meet resident needs. For a facility operating a locked unit, this means specifically addressing how the building is secured, what monitoring technology is in place, how staff are trained to respond to elopement attempts, and what protocols exist for accounting for all residents at regular intervals.
The nursing home administrator acknowledged the gaps during an interview with inspectors on February 26, 2025 at 5:33 p.m., stating she "did not remember specifically what was written about the needs of the resident in relation to needing to live in a totally secure facility." The administrator said she would meet with the leadership team and update the facility assessment to include more information on providing residents a safe and secure environment.
The deficiency was classified as affecting many residents with a harm level of minimal harm or potential for actual harm.
No Hospital Transfer Agreement on File
In a separate but related finding under F843, inspectors determined that Valley View did not have a written transfer agreement with any Medicare- or Medicaid-certified hospital. Federal regulations require nursing homes to maintain these agreements to ensure residents can be moved quickly and admitted to a hospital when medical circumstances require it.
When inspectors requested the hospital transfer agreement on February 26, 2025 at 2:10 p.m., the facility was unable to produce one. The administrator confirmed the following day that the facility "could not locate a hospital transfer agreement" and said she had reached out to the local hospital to get one completed.
The administrator acknowledged "it was important to have a hospital transfer agreement in case the facility needed to send a resident out."
Why Transfer Agreements Matter
Hospital transfer agreements establish pre-arranged protocols between nursing homes and hospitals that streamline the admission process during emergencies. Without such an agreement, a resident experiencing a medical crisis — including injuries sustained during an elopement event — could face delays in receiving hospital-level care. These agreements typically outline communication procedures, medical record transfers, and bed availability commitments that reduce critical time gaps during emergencies.
Regulatory Context
Valley View Health Care Center, located at 2120 N 10th St, Canon City, CO 81212, operates under federal provider number 065347. The facility is required to submit a plan of correction addressing each deficiency identified during the investigation.
Elopement prevention is a priority focus area for the Centers for Medicare & Medicaid Services. Facilities operating secured units bear a heightened responsibility to demonstrate that their physical plant, staffing levels, training programs, and monitoring systems are adequate to prevent unauthorized departures.
The combination of an incomplete facility assessment and a missing hospital transfer agreement suggests systemic gaps in Valley View's administrative oversight — gaps that directly affect the safety infrastructure residents depend on daily.
For complete inspection details, the full CMS-2567 survey report is available through the Centers for Medicare & Medicaid Services or by contacting the Colorado Department of Public Health and Environment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Health Care Center, Inc from 2025-02-26 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.