Valley Manor Care Center
1401 S Cascade Ave · Montrose, CO · 81401 · 9702499634
101 certified beds Non profit - Corporation Chain: Volunteers of America Senior Living
Why this verdict
- Carries CMS’s abuse warning icon.
- 5 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
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Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.19 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.89 | 0.55–0.75 |
| Weekend hours / resident-day | 3.64 | ≈ weekday level |
| Nursing turnover / year | 49% | median 45% |
| Fines (3-yr window) | 1 · $35,968 |
Inspection citations (28 in the current record)
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Potential for harm · D December 10, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 11, 2025 · Quality of Life and Care
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Actual harm · G May 23, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected June 20, 2024 · Quality of Life and Care
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Potential for harm · D May 23, 2024
Give the resident's representative the ability to exercise the resident's rights.
Corrected June 20, 2024 · Resident Rights
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Potential for harm · E May 23, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected June 20, 2024 · Resident Rights
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Potential for harm · D May 23, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 20, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 23, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected June 20, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 23, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected June 20, 2024 · Quality of Life and Care
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Potential for harm · D May 23, 2024
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 June 20, 2024 · Pharmacy Service
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Potential for harm · D May 23, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected June 20, 2024 · Nutrition and Dietary
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Potential for harm · E May 23, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected June 20, 2024 · Nutrition and Dietary
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Potential for harm · D May 23, 2024
Provide and implement an infection prevention and control program.
Corrected June 20, 2024 · Infection Control
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Actual harm · G June 8, 2023 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected May 19, 2023 · Quality of Life and Care
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Actual harm · G November 17, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 3, 2023 · Resident Rights
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Actual harm · G November 17, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G November 17, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected January 3, 2023 · Quality of Life and Care
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Potential for harm · D November 17, 2022
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected January 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 17, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 17, 2022
Respond appropriately to all alleged violations.
Corrected January 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 17, 2022
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected January 3, 2023 · Resident Assessment and Care Planning
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Potential for harm · D August 12, 2021
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 September 17, 2021 · Resident Rights
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Potential for harm · E August 12, 2021
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 19, 2021 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 12, 2021
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected September 17, 2021 · Resident Assessment and Care Planning
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Potential for harm · D August 12, 2021
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 17, 2021 · Quality of Life and Care
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Potential for harm · D August 12, 2021
Provide safe, appropriate pain management for a resident who requires such services.
Corrected September 19, 2021 · Quality of Life and Care
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Potential for harm · E August 12, 2021
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected September 17, 2021 · Nursing and Physician Services
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| May 23, 2024 | Fine | $35,968 |
Better-scoring options nearby
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 065119 · certified since November 1, 1972. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.