Cycle 1
Health 2024-05-23 · Fire 2024-05-23
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Montrose, CO
Valley Manor Care Center
3-star overall rating with 2-star inspections with abuse icon flag with $43,131 in total fines with 11 recent health deficiencies
1401 S Cascade Ave, Montrose, CO
(970) 249-9634
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
64
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Volunteers Of America Senior Living
Operator or chain grouping
Approved since
1972-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 2 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,145
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.64
Performance 19.75% · Measure score 3.64 · Achievement 3.64 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.86
Performance 6.38% · Measure score 4.86 · Achievement 4.86 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 43.28% · Performance 62.10% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.75
Baseline 4.02 hours · Performance 4.14 hours · Measure score 3.75 · Achievement 3.75 · Improvement 0.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 6.45% · Lower 95% interval 6.7% |
| Discharge to community | 59.92% |
50.57%
9.4 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 59.62% · Lower 95% interval 49.36% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 39 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 72.73% |
53.69%
19 pts better
|
Numerator 24 · Denominator 33 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 11 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.38% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 2.33% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 2.04% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 98 |
| Staff flu vaccination coverage | 65.12% |
42%
23.1 pts better
|
Numerator 84 · Denominator 129 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 22 · Denominator 33 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 2 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.3
0.8 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.7
1.5 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
93.5%
5.6 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
94.7%
3.5 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.4%
3.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
7.4%
0.6 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.0% · Q3 6.1% · Q4 7.3% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.0%
1.3 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.3% · Q3 0.0% · Q4 2.3% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
11.2%
4.2 pts worse
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 12.5% · Q3 16.7% · Q4 15.9% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.2% |
20.6%
9.6 pts worse
|
16.7%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 36.4% · Q3 29.2% · Q4 22.6% · 4Q avg 30.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.0% |
15.2%
9.8 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
14.6%
0.6 pts worse
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.4% · Q3 16.7% · Q4 18.2% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.8%
0.5 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.5%
0.4 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 1.9% · Q4 1.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
22.4%
5.1 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 28.1% · Q3 28.8% · Q4 26.7% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
3.7%
0.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 4.8% · Q4 6.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
76.4%
16.8 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 94.1% · Q3 96.4% · Q4 90.6% · 4Q avg 93.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
12.8%
8.8 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 3.4% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
75.6%
18.7 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
20.3%
5.2 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 13.8% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-17 · Fire 2022-11-17
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-08-12 · Fire 2021-08-12
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-11
G · Actual harm
2024-05-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-05-23
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-05-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-23
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-23
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-23
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
G · Actual harm
2023-06-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-19
G · Actual harm
2022-11-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-01-03
G · Actual harm
2022-11-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-03
G · Actual harm
2022-11-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-03
F · Potential for more than minimal harm
2021-08-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-09-19
E · Potential for more than minimal harm
2021-08-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-09-19
D · Potential for more than minimal harm
2021-08-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-12
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-09-17
Penalties and ownership
What sits behind the stars
$35,968
2024-05-23
Fine
Fine · fine $35,968
Fine
$7,163
2023-06-08
Fine
Fine · fine $7,163
Fine
Ownership
Volunteers Of America National Services
5% Or Greater Indirect Ownership Interest · Organization
Arnold, Patti
Corporate Director · Individual
Bloom, Shawn
Corporate Director · Individual
Budzynski, Joseph
Corporate Officer · Individual
Burkes, Jane
Corporate Director · Individual
Burrell, James
W-2 Managing Employee · Individual
Carrington, Edwina
Corporate Director · Individual
Dale, Karen
Corporate Director · Individual
Dolan, Thomas
Corporate Director · Individual
Edeburn, Andrew
Corporate Director · Individual
Gavin, Nancy
Corporate Officer · Individual
King, Michael
Corporate Director · Individual
Knapp, Keith
Corporate Director · Individual
Leblanc, James
Corporate Director · Individual
Mullen, Beth
Corporate Director · Individual
Nickell, Jacci
Operational/Managerial Control · Individual
Nutz, Faith
Corporate Officer · Individual
Perkins, Derrick
Corporate Director · Individual
Peterson, Jeanne
Corporate Director · Individual
Rase, Nancy
Corporate Director · Individual
Volunteers Of America National Services
Operational/Managerial Control · Organization
Wakefield, Stephen
Corporate Director · Individual
Wilson-Geno, Sharon
Corporate Officer · Individual
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