Valley Manor Care Center
1401 S Cascade Ave, Montrose, CO 81401 · Montrose County · 101 certified beds · avg 66 residents/day · certified since Nov 1, 1972
Abuse citation flag (CMS)
Part of chain: VOLUNTEERS OF AMERICA SENIOR LIVING (6 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 23, 2024 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 20, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 17, 2022 · F-0550
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 3, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 17, 2022 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 3, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 17, 2022 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 3, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 9, 2026 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Dec 10, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 23, 2024 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| May 23, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 17, 2022 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Nov 17, 2022 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Nov 17, 2022 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 17, 2022 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. |
| Nov 17, 2022 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Nov 17, 2022 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Nov 17, 2022 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 7 | 3 | G ▲ |
| 2024 | 10 | 1 | G ▲ |
| 2025 | 1 | 0 | D |
| 2026 | 10 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $35,968.
| Date | Type | Amount / length |
|---|---|---|
| May 23, 2024 | Fine | $35,968 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.40 | 3.89 | 3.95 | top 23% in Colorado; top 26% in the U.S. |
| Registered Nurse hours | 0.98 | 0.86 | 0.69 | top 29% in Colorado; top 16% in the U.S. |
| Weekend total nurse staffing | 3.77 | 3.44 | 3.50 | top 25% in Colorado; top 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.53 | 0.61 | 0.48 | bottom 49% in Colorado; top 30% in the U.S. |
| Total nursing staff turnover (%) | 40.3 | 47.1 | 45.8 | top 30% in Colorado; top 37% in the U.S. |
| RN turnover (%) | 43.8 | 44.6 | 42.9 | top 47% in Colorado; bottom 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.10, RN 0.92, weekend 3.51. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Beaty, Dejernette | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Bloom, Shawn | Individual | Corporate Director | NOT APPLICABLE | 03/23/2010 |
| Budzynski, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 04/02/2012 |
| Chakravarty, Debashish | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Erickson, Karen | Individual | Corporate Director | NOT APPLICABLE | 07/01/2022 |
| Hackett, Karen | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Hackett, Karen | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Jackson, Carmen | Individual | Corporate Director | NOT APPLICABLE | 07/01/2025 |
| King, Michael | Individual | Corporate Director | NOT APPLICABLE | 07/01/2010 |
| Mullen, Beth | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Mullen, Beth | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Nisivoccia, David | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2024 |
| Nutz, Faith | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2018 |
| Nutz, Faith | Individual | ADP of the SNF | NOT APPLICABLE | 09/18/2018 |
| Paskoff, David | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2024 |
| Perkins, Derrick | Individual | Corporate Director | NOT APPLICABLE | 07/01/2019 |
| Perkins, Derrick | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2024 |
| Peterson, Jeanne | Individual | Corporate Director | NOT APPLICABLE | 07/01/2017 |
| Sheridan, Patrick | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Soczynski, Paul | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/20/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Hope Springs Care Center | 0.6 mi | Montrose, CO | ★★☆☆☆ | 2/5 | |
| Colorow Care Center | 11.8 mi | Olathe, CO | ★★★☆☆ | 2/5 | abuse |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065119.