Valley Rehab: Care Plan Failures Put Residents at Risk - CO
That gap, between recognizing a problem and documenting the fix, was at the center of a complaint inspection completed September 11, 2025, at the small rural facility in Mancos, Colorado.
Inspectors cited the facility under F0657, which covers the development and revision of individualized care plans. The deficiency was rated at the lower end of the harm scale, meaning inspectors found minimal harm or the potential for actual harm, and it affected a small number of residents. But the people responsible for running the facility acknowledged, in their own words, that the system for getting fall prevention steps onto paper, and then into the hands of the aides doing the work, had not been functioning the way it should.
The facility's MDS coordinator told inspectors she was still learning the care plan process and trying to personalize plans for each resident. She said she had launched a facility-wide care plan audit to identify gaps, but had not had the chance to finish it or make the needed changes. Her goal, she said, was to add new fall prevention interventions to care plans right away after the morning meeting, as long as those interventions could be immediately put in place.
She explained why it mattered. The care plan, she said, was a form of communication. It was how staff knew the personalized steps for caring for each resident. Once interventions were on the care plan, they could be transferred to the Kardex, the working document that aides consult during their shifts. Without that transfer, a certified nursing assistant could be caring for a resident flagged as a fall risk and have no written guidance on what specific steps to take.
The nursing home administrator and the director of nursing were interviewed together on the morning of the inspection. The administrator said that going forward, the interdisciplinary team would stay in the at-risk meeting until all newly identified fall interventions had been added to the care plans before anyone left the room. The director of nursing added that when an intervention required permission from a resident's representative, the care plan would be updated as soon as that permission came in.
The administrator also said the facility had started Kardex training that same day, September 11, to make sure all CNAs knew how to access the Kardex and identify fall prevention interventions for residents who were at risk.
That the training began on the day inspectors were on-site is worth noting. It is not an accusation. Facilities sometimes accelerate corrective steps when a survey is underway. What the timing does reflect is that, before that morning, not all aides had been trained on how to find fall prevention information for the residents they were caring for.
Fall prevention in a nursing home is not a single action. It is a chain. A resident is identified as at risk. The clinical team figures out what that particular person needs, maybe a bed alarm, maybe a specific walking assist, maybe scheduled hourly checks, maybe shoes with better grip. That plan gets written down. It gets transferred to the document aides carry with them. The aides read it and follow it. If any link in that chain breaks, the plan exists on paper but not in practice.
At Valley Rehabilitation, inspectors found the chain had broken between the meeting room and the care plan.
The facility is small and rural, sitting in Montezuma County in the southwest corner of Colorado. The MDS coordinator's candor with inspectors, her acknowledgment that she was still learning the process and had not finished the audit, suggests a facility working through staffing or transition challenges rather than one indifferent to the problem. The administrator's commitment to keeping the team in the room until care plans were updated before adjourning is a concrete operational change.
But somewhere in the period before the inspection, residents who had fallen, residents the staff themselves had identified as needing new protections, were being cared for by aides who may not have known what those protections were.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Rehabilitation and Healthcare Center, The from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
VALLEY REHABILITATION AND HEALTHCARE CENTER, THE in MANCOS, CO was cited for violations during a health inspection on September 11, 2025.
Inspectors cited the facility under F0657, which covers the development and revision of individualized care plans.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.