Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 2
Date: Sep 23, 2025
Visit Reason
The inspection was conducted based on complaints regarding medication administration practices and medical record accuracy at the Rehabilitation and Nursing Center of the Rockies.
Complaint Details
The complaint investigation found substantiated issues related to medication administration and documentation for Resident #9 and medical record inaccuracies for Resident #5.
Findings
The facility failed to ensure proper medication administration practices for Resident #9, including leaving medications unattended and inaccurate documentation. Additionally, the facility failed to maintain accurate medical records for Resident #5, specifically regarding the administration and documentation of Cardura medication.
Deficiencies (2)
Failure to ensure nurses did not leave medications on Resident #9's bedside table and to ensure medications were swallowed and properly documented.
Failure to maintain accurate medical records for Resident #5, including inaccurate documentation of Cardura medication administration.
Report Facts
Residents in sample: 13
Residents affected: 1
Residents affected: 1
BIMS score: 10
BIMS score: 15
Medication doses not administered: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency for leaving medications unattended and failing to ensure Resident #9 swallowed medications |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration practices |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration practices |
| Director of Nursing | Director of Nursing (DON) | Observed medication administration issues and conducted staff interviews |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Provided facility policies and participated in interviews |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Participated in interviews regarding medication administration |
| Nursing Home Administrator #2 | Nursing Home Administrator (NHA) | Participated in interviews regarding medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 23, 2025
Visit Reason
The inspection was conducted based on observations, record review, and interviews to investigate complaints regarding medication administration and medical record accuracy at the nursing facility.
Complaint Details
The complaint investigation focused on medication administration errors for Resident #9, including leaving medications unattended and inaccurate documentation, and on inaccurate medical record documentation for Resident #5's medication administration of Cardura. The findings were substantiated.
Findings
The facility failed to ensure nurses properly administered and documented medications for Resident #9, including leaving medications unattended and inaccurate documentation. The facility also failed to maintain accurate medical records for Resident #5's medication administration of Cardura, with documentation errors and lack of physician hold orders.
Deficiencies (2)
F 0658: The facility failed to ensure nurses did not leave medications on Resident #9's bedside table and did not document medication administration accurately, risking medication errors.
F 0842: The facility failed to maintain medical records in accordance with accepted professional standards for Resident #5 by inaccurately documenting medication administration of Cardura and lacking proper hold orders.
Report Facts
Sample residents reviewed: 13
Residents affected: 1
Residents affected: 1
Resident #9 BIMS score: 10
Resident #5 BIMS score: 15
Medication doses documented but not administered: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency for leaving medications unattended and inaccurate documentation for Resident #9 |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and deficiencies |
| LPN #1 | Licensed Practical Nurse | Interviewed about proper medication administration and documentation practices |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication administration and documentation practices |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided facility policies and participated in interviews |
| Nursing Home Administrator #2 | Nursing Home Administrator | Interviewed regarding medication administration deficiencies |
Inspection Report
Deficiencies: 11
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident rights, care, safety, abuse prevention, mental health services, activities, infection control, and overall facility administration.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights to choose their physician, inadequate grievance follow-up, improper use of psychotropic medications, failure to investigate injuries and abuse allegations timely and thoroughly, insufficient discharge documentation, failure to implement PASRR recommendations, inadequate activities programming, failure to prevent accidents and falls, inadequate mental health monitoring and treatment, ineffective leadership and administration, and lapses in infection control practices.
Deficiencies (11)
Failed to honor resident's right to choose attending physician.
Failed to provide response, action and rationale to residents involved in group grievances.
Failed to prevent unnecessary psychotropic medication use and failed to document resident-specific behaviors and care approaches.
Failed to respond appropriately to alleged violations including verbal abuse and injury of unknown origin.
Failed to provide and document sufficient discharge preparation and notification for resident leaving against medical advice.
Failed to incorporate PASRR Level II recommendations including neurocognitive evaluation for resident with serious mental illness.
Failed to provide an ongoing personalized activity program to meet resident's needs and interests.
Failed to ensure adequate supervision and fall prevention interventions resulting in injury and repeated falls.
Failed to provide appropriate treatment and services to resident with mental disorder including monitoring for suicidal ideation.
Failed to administer facility resources effectively including leadership, abuse investigation, injury investigation, and mental health monitoring.
Failed to maintain infection control program including hand hygiene, laundry separation, hygienic handling of cups, tracheostomy care, and catheter bag sanitation.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in injury of unknown origin finding for Resident #4 |
| RN #2 | Registered Nurse | Named in verbal abuse allegation involving Resident #24 |
| CNA #4 | Certified Nurse Aide | Named in verbal abuse allegation involving Resident #24 |
| NHA | Nursing Home Administrator | Named in leadership and abuse investigation findings |
| SSD | Social Services Director | Named in grievance and mental health monitoring findings |
| DON | Director of Nursing | Named in leadership and abuse investigation findings |
| INHA | Interim Nursing Home Administrator | Named in leadership findings |
| CNA #1 | Certified Nurse Aide | Named in activities and fall prevention findings |
| RN #1 | Registered Nurse | Named in tracheostomy care and fall prevention findings |
| MDSC | Minimum Data Set Coordinator | Named in fall prevention and infection control findings |
| CR #2 | Clinical Resource | Named in tracheostomy care and infection control findings |
| MTD | Maintenance Director | Named in laundry and infection control findings |
| IP | Infection Preventionist | Named in infection control findings |
| AD | Activities Director | Named in activities findings |
| DOR | Director of Rehabilitation | Named in fall prevention findings |
| RCR | Regional Clinical Resource | Named in fall prevention findings |
| Pharmacist | Named in fall prevention findings |
Inspection Report
Deficiencies: 11
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident rights, care, safety, abuse prevention, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights to choose their attending physician, inadequate response to resident grievances, improper use and documentation of psychotropic medications, failure to investigate allegations of abuse and injury of unknown origin, insufficient discharge documentation, failure to incorporate PASRR recommendations, inadequate activity programming, failure to prevent accidents and falls, failure to provide appropriate mental health services, ineffective leadership and administration, and lapses in infection prevention and control practices.
Deficiencies (11)
F 0555: The facility failed to ensure one resident was allowed to choose their attending physician when the previous provider stopped seeing residents.
F 0565: The facility failed to provide response, action, and rationale to residents involved in group grievances and failed to follow up on grievances expressed.
F 0605: The facility failed to ensure two residents were free from chemical restraints and failed to document resident-specific behaviors and care approaches related to psychotropic medications.
F 0610: The facility failed to respond appropriately to allegations of staff-to-resident verbal abuse and failed to initiate a thorough investigation of an injury of unknown origin.
F 0628: The facility failed to provide and document sufficient discharge preparation and notification when a resident left against medical advice.
F 0644: The facility failed to incorporate recommendations from the PASRR Level II evaluation for a resident with serious mental illness, including failure to arrange a neurocognitive evaluation.
F 0679: The facility failed to provide an ongoing personalized activity program to meet the needs and interests of a resident with dementia and cognitive impairment.
F 0689: The facility failed to ensure two residents received adequate supervision to prevent accidents and falls, including failure to transfer a resident properly resulting in fractures and failure to implement person-centered fall interventions for another resident.
F 0742: The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder, including failure to monitor for worsening depression and suicidal ideation.
F 0835: The facility failed to administer resources effectively and efficiently, including failure to provide sufficient leadership, timely abuse investigations, injury investigations, and monitoring of residents with depression and suicidal ideation.
F 0880: The facility failed to maintain an infection control program, including failure to ensure housekeeping staff performed hand hygiene between rooms, separation of clean and soiled laundry, hygienic handling of drinking cups, sanitary tracheostomy care, and proper cleaning and storage of a urinary catheter drainage bag.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in failure to assess and report injury to Resident #4 |
| RN #2 | Registered Nurse | Named in allegations of verbal abuse to Resident #24 |
| CNA #4 | Certified Nurse Aide | Named in allegations of verbal abuse to Resident #24 |
| NHA | Nursing Home Administrator | Named in failure to timely investigate abuse allegations and leadership deficiencies |
| SSD | Social Services Director | Named in grievance and abuse investigation deficiencies |
| DON | Director of Nursing | Named in grievance and abuse investigation deficiencies |
| MDSC | Minimum Data Set Coordinator | Named in fall prevention and infection control deficiencies |
| CR #2 | Clinical Resource | Named in infection control deficiencies |
| RN #1 | Registered Nurse | Named in tracheostomy care deficiency |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 23, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding care and assistance with activities of daily living, fall prevention, and safety supervision.
Findings
The facility failed to provide adequate assistance with meal set up and eating for multiple residents with cognitive impairments, resulting in minimal harm or potential for harm. Additionally, the facility failed to ensure wheelchair foot pedals were attached during resident transport, posing a fall risk.
Deficiencies (2)
Failure to provide timely person-centered assistance with meal set up and/or eating for residents #3, #9, and #12.
Failure to ensure wheelchair pedals were attached to residents #10 and #11's wheelchairs prior to pushing, creating a safety hazard.
Report Facts
Residents in sample: 20
Residents affected: 3
Residents affected: 2
BIMS score: 1
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #9's meal assistance and facility dining procedures |
| CNA #3 | Certified Nurse Aide | Observed and interviewed regarding assistance with eating for Resident #3 |
| CNA #6 | Certified Nurse Aide | Observed assisting residents with eating, including Resident #3 |
| CNA #8 | Certified Nurse Aide | Interviewed about meal assistance practices and staffing |
| CNA #9 | Certified Nurse Aide | Interviewed about meal assistance staffing and resident needs |
| DON | Director of Nursing | Interviewed regarding facility policies on meal assistance and wheelchair safety |
| ADON | Assistant Director of Nursing | Interviewed regarding staffing and assistance with eating |
| CRN | Clinical Resource Nurse | Interviewed with DON and ADON about meal assistance policies |
| DOR | Director of Rehabilitation | Interviewed about wheelchair foot pedal safety and resident education |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident care, including assistance with activities of daily living and safety supervision in a nursing home setting.
Findings
The facility failed to provide adequate assistance with meal set up and eating for multiple residents with cognitive impairments, and failed to ensure wheelchair foot pedals were attached to prevent safety hazards during resident transport.
Deficiencies (2)
F 0677: The facility failed to provide timely, person-centered assistance with meal set up and eating for Residents #3, #9, and #12, resulting in inadequate support during meals.
F 0689: The facility failed to ensure wheelchair foot pedals were attached to Residents #10 and #11's wheelchairs prior to pushing, creating a safety hazard.
Report Facts
Residents in sample: 20
Residents affected: 3
Residents affected: 2
BIMS score: 1
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #9's meal assistance and facility dining procedures |
| CNA #3 | Certified Nurse Aide | Observed and interviewed regarding meal assistance to Resident #3 |
| CNA #8 | Certified Nurse Aide | Interviewed about meal assistance for Residents #3 and #12 and staffing challenges |
| CNA #9 | Certified Nurse Aide | Interviewed about meal assistance procedures and Resident #12's needs |
| DON | Director of Nursing | Interviewed about facility policies on meal assistance and wheelchair safety |
| ADON | Assistant Director of Nursing | Interviewed about staffing and assistance during meals |
| DOR | Director of Rehabilitation | Interviewed about wheelchair foot pedal safety and resident education |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 1, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate supervision to prevent accidents and failure to provide safe, appropriate pain management for residents.
Complaint Details
The complaint investigation found that Resident #2 did not receive adequate supervision to prevent falls, and Residents #7 and #8 did not have documented parameters for pain medication administration. The facility's internal fall risk awareness system was not effectively communicated to staff, and fall interventions were not consistently implemented. Pain medication orders lacked specific pain level parameters for administration.
Findings
The facility failed to ensure consistent implementation of fall prevention interventions for Resident #2 following a fall resulting in a wrist fracture. Additionally, the facility failed to manage pain appropriately for Residents #7 and #8 by not documenting parameters for pain medication administration.
Deficiencies (2)
Failed to ensure identified person-centered fall interventions were implemented consistently for Resident #2 following a fall with a left wrist fracture.
Failed to manage pain of Residents #7 and #8 in a manner consistent with professional standards, specifically lacking documented parameters for pain medication administration.
Report Facts
Residents in sample: 9
Residents affected: 2
Residents affected: 1
BIMS score: 15
BIMS score: 15
BIMS score: 14
Pain medication dosage: 325
Pain medication dosage: 5
Pain medication dosage: 650
Pain medication frequency: 6
Pain medication frequency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding fall interventions and pain medication parameters |
| CNA #1 | Certified Nurse Aide | Interviewed regarding fall mat placement and fall interventions |
| DON | Director of Nursing | Provided facility policies and interviewed about fall risk interventions |
| ADON | Assistant Director of Nursing | Interviewed about fall risk interventions and interdisciplinary team meetings |
| CN #1 | Charge Nurse | Interviewed regarding pain medication administration for Resident #8 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision to prevent accidents and failure to provide safe, appropriate pain management for residents.
Complaint Details
The investigation was triggered by complaints concerning inadequate supervision to prevent falls and improper pain management. The complaint was substantiated based on observations, record reviews, and staff interviews confirming failures in fall intervention implementation and pain medication order parameters.
Findings
The facility failed to consistently implement fall prevention interventions for Resident #2 after a fall resulting in a wrist fracture. Additionally, the facility failed to ensure pain medication orders for Residents #7 and #8 included documented parameters for administration, leading to inadequate pain management.
Deficiencies (2)
F 0689: The facility failed to ensure identified person-centered fall interventions were consistently implemented for Resident #2 following a fall with a left wrist fracture. Staff did not place fall mats and bolsters as care planned, and supervision was inadequate.
F 0697: The facility failed to ensure pain medication orders for Residents #7 and #8 included documented parameters for administration. Physician orders lacked pain level guidelines, and staff confirmed medications were administered without clear parameters.
Report Facts
Residents in sample: 9
Residents with fall supervision issues: 1
Residents with pain management issues: 2
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding concerns raised by Resident #65 about being treated without respect and dignity, and issues related to interactions with Resident #74, including safety and care plan concerns.
Complaint Details
The complaint involved Resident #65 reporting discomfort and safety concerns due to Resident #74's behavior, including unwanted touching and wandering into her room. Resident #65 felt staff did not adequately address her concerns, and she was asked to stay off certain hallways without alternative activities offered. The facility's response and documentation were inadequate, and Resident #65 was offered counseling and relocation options which she declined.
Findings
The facility failed to ensure Resident #65 was treated with respect and dignity, failed to update her care plan with her involvement, and did not document her concerns properly. Additionally, the facility failed to provide appropriate dementia care and services to Resident #74, including the development and implementation of comprehensive care plans addressing wandering and behavior issues.
Deficiencies (2)
Failed to ensure Resident #65 was treated with respect and dignity after reporting concerns, including lack of alternative activities and care plan updates.
Failed to provide appropriate treatment and services to Resident #74 with dementia, including lack of comprehensive care plans for wandering and mood/behavior prior to survey.
Report Facts
Residents reviewed: 40
Resident #65 care plan initiation date: 2023
Resident #74 BIMS score: 6
Resident #65 BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Registered Nurse | Interviewed regarding Resident #65 and #74 interactions and care concerns |
| Social Services Director | Social Services Director (SSD) | Interviewed about counseling offers and documentation related to Resident #65 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff supervision and care plan updates |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding overall facility response to Resident #65 and #74 concerns |
| Certified Nurse Aide #6 | Certified Nurse Aide (CNA) | Interviewed about staff attitudes and Resident #65 hair dye provision |
| Restorative Nurse Aide #1 | Restorative Nurse Aide (RNA) | Interviewed about Resident #65 activities and hair dye provision |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding concerns about resident dignity, respect, and care, specifically involving Resident #65 and interactions with Resident #74.
Complaint Details
The complaint involved Resident #65 reporting discomfort and safety concerns due to Resident #74's behavior, including unwanted touching and wandering into her room. Resident #65 felt staff did not adequately address her concerns, and the facility's response was insufficient, including lack of proper monitoring and care plan updates. The complaint also included failure to provide adequate dementia care and wandering interventions for Resident #74.
Findings
The facility failed to ensure Resident #65 was treated with respect and dignity, failed to update her care plan with her involvement, and did not document her concerns properly. The facility also failed to provide appropriate dementia care and wandering interventions for Resident #74, including lack of a comprehensive care plan and person-centered interventions.
Deficiencies (2)
F 0550: The facility failed to honor Resident #65's right to a dignified existence, self-determination, communication, and to exercise her rights, including failure to treat her with respect after reporting concerns, failure to offer alternative activities, failure to update her care plan with her involvement, and failure to document her concerns and interventions.
F 0744: The facility failed to provide appropriate treatment and services to Resident #74 with dementia, including failure to develop a comprehensive plan of care with person-centered interventions to address wandering behaviors and mood/behavior issues prior to the survey.
Report Facts
Residents reviewed: 40
Resident #65 interview dates: 3
Resident #74 observation dates: 3
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
Annual survey inspection of the Rehabilitation and Nursing Center of the Rockies to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home inspection conducted on 08/22/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide services by qualified persons according to each resident's written plan of care, specifically related to licensed practical nurses performing duties outside their scope of practice and improper documentation.
Complaint Details
The complaint investigation found that LPNs performed IV/PICC line flushes and documented RN procedures without proper certification or qualifications. The facility confirmed that only one LPN had IV certification and that LPNs should not perform duties outside their scope of practice. The documentation was often incomplete or improperly signed, indicating noncompliance with facility policy and regulatory requirements.
Findings
The facility failed to ensure that licensed practical nurses (LPNs) performed duties within their scope of practice, including intravenous/PICC line flushes and procedures without proper qualifications or certification. Additionally, LPNs documented procedures that were ordered to be completed by registered nurses (RNs), and there was a lack of proper signatures and documentation on medication administration records and progress notes. Only one LPN had IV certification among eight employed, and LPNs were educated on scope of practice violations.
Deficiencies (2)
Staff who were licensed practical nurses (LPN) performed intravenous/PICC line flushes and procedures without qualifications or certification.
LPNs did not chart under the registered nurse (RN) designated orders on the medication and treatment administration record (MAR/TAR) and in progress notes for procedures to be completed by an RN.
Report Facts
Residents reviewed: 23
Residents affected: 2
LPNs employed: 8
LPNs with IV certification: 1
PICC flush volume: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented RN procedures without proper certification; involved in documentation deficiencies |
| LPN #2 | Licensed Practical Nurse | Documented RN procedures without proper certification; interviewed about charting practices |
| LPN #3 | Licensed Practical Nurse | Only LPN with IV certification; did not chart on Residents #21 or #9 |
| LPN #4 | Licensed Practical Nurse | Documented RN procedures without proper certification; involved in documentation deficiencies |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding facility policy and scope of practice |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding facility policy and scope of practice |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding facility policy and scope of practice |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide services by qualified persons according to each resident's written plan of care, specifically concerning licensed practical nurses performing duties outside their scope of practice.
Complaint Details
The complaint investigation found substantiated issues with LPNs performing IV/PICC line flushes and procedures without proper certification and improper documentation practices. The facility acknowledged these issues and provided education to staff.
Findings
The facility failed to ensure that licensed practical nurses (LPNs) did not perform intravenous/PICC line flushes and procedures without proper qualifications or certification. LPNs also improperly charted under registered nurse (RN) orders on medication and treatment administration records and progress notes. Several instances showed lack of proper signatures and documentation by RNs for procedures that were ordered to be completed by RNs.
Deficiencies (1)
F0659: The facility failed to provide care by qualified persons according to each resident's written plan of care. LPNs performed IV/PICC line flushes and procedures without required IV certification and charted treatments they did not perform, violating scope of practice rules.
Report Facts
Residents reviewed: 23
Residents affected: 2
LPNs employed: 8
LPNs with IV certification: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented RN procedures without proper certification and charting |
| LPN #2 | Licensed Practical Nurse | Interviewed and admitted to charting treatments she did not perform |
| LPN #3 | Licensed Practical Nurse | Only LPN with IV certification; did not chart on Residents #21 or #9 |
| LPN #4 | Licensed Practical Nurse | Documented RN procedures without proper certification and charting |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policy and staff education |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding facility policy and staff education |
| Infection Preventionist | Infection Preventionist | Interviewed regarding facility policy and staff education |
Inspection Report
Deficiencies: 2
Date: Nov 21, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to the use of physical restraints and the provision of professional quality care in the nursing facility.
Findings
The facility failed to ensure proper assessments, physician orders, consents, monitoring, and care planning for the use of a lap belt restraint on one resident. Additionally, the facility failed to follow physician orders for notification of significant weight gain for another resident, potentially delaying treatment.
Deficiencies (2)
Failure to perform initial and quarterly assessments for the use of a lap belt restraint, obtain physician's order and consent, develop monitoring system and care plan addressing underlying problems and restraint reduction.
Failure to follow physician orders for notification of weight gain which could lead to delayed treatment.
Report Facts
Residents reviewed: 31
Weight gain events: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Provided facility policy and interview statements regarding lap belt use | |
| Staff Development Coordinator (SDC) | Interviewed regarding resident lap belt assessment and consent | |
| Assistant Director of Nursing (ADON) | Interviewed regarding assessments, physician orders, and care plan for lap belt | |
| Minimum Data Set Coordinator (MDSC) | Interviewed regarding lap belt use and coding on MDS | |
| Director of Nursing (DON) | Provided facility policy and interview statements regarding physician orders and weight gain notifications |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding the improper use of physical restraints and failure to follow physician orders for resident care at the Rehabilitation and Nursing Center of the Rockies.
Complaint Details
The investigation was complaint-driven, focusing on improper use of physical restraints and failure to follow physician orders for weight monitoring and notification. The findings confirmed deficiencies in both areas.
Findings
The facility failed to ensure residents were free from physical restraints used for convenience without proper assessments, physician orders, or consent. Additionally, the facility failed to notify the physician of significant weight gains in a resident as ordered, potentially delaying treatment.
Deficiencies (2)
F 0604: The facility failed to perform initial and quarterly assessments, obtain physician orders and consent, develop monitoring systems, and create care plans addressing the use of a lap belt restraint for one resident.
F 0658: The facility failed to follow physician orders to notify the provider of significant weight gains in one resident, leading to possible delayed treatment.
Report Facts
Weight gain incidents: 9
Sample residents reviewed: 31
Residents affected: 1
Residents affected: 1
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