Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
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
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
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
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: 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
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
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
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 |
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