South Valley Post Acute: Safety Hazards Found - CO
The nursing assistant, identified in inspection records only as CNA #5, said she had no idea the resident's transfer status had changed. She found out the same way inspectors did: after the second incident.
The resident, referred to as Resident #2, had already been through a fall serious enough to trigger a care plan revision. After that fall, the facility's interdisciplinary team updated her care plan to require a two-person assist for all transfers. That update made it into the care plan document. It did not make it onto the CNA task list, the daily record nursing assistants use to know what each resident needs.
CNA #5 was the one left without that information.
She described what happened when she went to transfer Resident #2 from the bed to a wheelchair. The resident looked wobbly and weak. CNA #5 tried to sit her back on the edge of the bed. The resident was wearing non-slip socks and a gait belt, but she had to be assisted to the ground. The inspection report calls it an "assisted fall." The resident ended up on the floor.
CNA #5 had been working under the assumption that Resident #2 was a one-person transfer, because that was the last thing anyone had officially communicated to her.
The Director of Nursing confirmed the gap during two separate interviews with inspectors on the day of the inspection. In the first interview, she described the facility's standard protocol after a fall: determine the root cause using an interdisciplinary team approach, make sure the resident is safe and can reach her call light, update the care plan with new interventions. She said the care plan had in fact been updated after Resident #2's earlier fall, with the two-person transfer requirement added.
Then inspectors asked whether a two-person transfer had actually occurred at the time of the second incident.
The DON said she was unable to determine that.
In a second interview roughly ninety minutes later, the DON was more direct. CNA #5 had transferred Resident #2 independently. CNA #5 did not know the resident had become a two-person assist. The new intervention, the DON said, had not been transcribed onto the CNA task list. That gap, she acknowledged, was why CNA #5 had no knowledge of the resident's current transfer status.
The care plan said one thing. The task list said nothing. The nursing assistant had only the task list.
This is a complaint inspection, meaning someone reported a concern to regulators before inspectors arrived. The inspection was conducted January 29, 2026, and covers a single deficiency, rated at minimal harm or potential for actual harm. CMS assigned the violation to a category affecting some residents.
The citation level reflects that no serious injury was documented in the inspection report. What the report does document is a system failure that played out exactly as such failures do: a decision was made at one level of the organization, recorded in one place, and never reached the person responsible for carrying it out. The care plan was updated. The task list was not. CNA #5 walked into that room without the one piece of information that would have changed what she did next.
Resident #2 ended up on the floor a second time. The DON, by her own account, could not say with certainty whether a second person had been present for any transfer after the first fall. The answer, once CNA #5 was interviewed, was that there had not been.
The gait belt was on. The non-slip socks were on. The second staff member was never called, because nobody had written down that she was needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Valley Post Acute Rehabilitation from 2026-01-29 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: August 9, 2026 · Our methodology
SOUTH VALLEY POST ACUTE REHABILITATION in DENVER, CO was cited for violations during a health inspection on January 29, 2026.
The nursing assistant, identified in inspection records only as CNA #5, said she had no idea the resident's transfer status had changed.
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.