Valley Rehabilitation And Healthcare Center, The

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's EMR contact list.-However, the resident representative's name was misspelled in the email address listed on the resident's EMR contact list (see record review above). The NHA and the BOM were interviewed together on 9/10/25 at 3:05 p.m. The NHA compared the email address she had for Resident #1's representative with the email address on the resident's EMR contact list and said the representative's email address was documented incorrectly on the contact list. She said it was facility's error and she would make sure Resident #1's received all requested medical records to the appropriate email address. The BOM said she would update Resident #1's EMR contact list with the representative's correct email address.

The NHA said she would make sure that any new resident/resident representative contact information would be provided to the facility in writing and then added to the resident's EMR. The NHA was interviewed again on 9/10/25 at 3:25 p.m. The NHA said the facility tried to send medical record requests within 48 hours, excluding holidays and weekends, but believed the facility had 30 days to send the medical records.

The NHA reviewed the medical record policy and said the facility should have provided the medical records to Resident #1's representative within 48 hours. She said to help with the timeliness of medical records requests, she would educate the medical records director on the appropriate timeline. She said the facility would conduct an audit of all of the residents' EMR contacts to ensure the facility had accurate records for

the contact information for residents' representatives. The medical records director was interviewed again

on 9/11/25 at 10:34 p.m. The medical records director said the NHA informed her that the facility's policy stated the facility should provide medical record requests to the resident's representative within 48 hours

after the receipt of the PHI authorization release form. The medical records director said a medical record assistant was recently hired. She said the additional staff member would ensure someone from medical records was at the facility five days a week and provide timeliness of record requests. V. Facility follow upThe NHA was interviewed a third time on 9/10/25 at 3:09 p.m. She said she sent Resident #1's representative the requested medical records to the correct email address on 9/10/25. Review of the email sent by the NHA identified that the email was sent to the resident's representative on 9/10/25 at 3:07 p.m.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Rehabilitation and Healthcare Center, The

211 E 3rd Ave Mancos, CO 81328

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

time the resident's needs would change. She said she was continuing to try to learn the facility's care plan process and trying to personalize each resident's care plan. She said care plans should be updated to continue to meet the resident's needs. The MDS coordinator said she had started a facility-wide care plan audit to make sure that residents' care plans were updated and included all appropriate interventions. She said she had not had the opportunity to complete the audit and make the needed changes/interventions.

She said the IDT reviewed the residents' falls during the morning meeting and her goal was to then add new fall prevention interventions to the care plans right away if the interventions could be immediately implemented. The MDS coordinator said it was important to make sure interventions were on the care plan so the personal-centered interventions could be transferred to the Kardex. She said the care plan was a form of communication so staff knew the personalized steps to take care of each resident. The NHA and

the DON were interviewed again together on 9/11/25 at 11:25 a.m. The NHA said moving forward, she would make sure the IDT would stay in the at-risk meeting until all the newly identified fall interventions were updated on the care plans. The DON said if some of the interventions required permission from the residents' representatives, they would update the care plan with the interventions as soon as the facility obtained the needed permission. The NHA said the facility had started a Kardex training today (9/11/25) to ensure all the CNAs were familiar with how to access the residents' Kardex and identify the fall prevention interventions for residents at risk for falling.

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If continuation sheet