Inspection Reports for
Rio Grande Rehabilitation and Healthcare Center
39 CALLE MILLER, La Jara, CO, 81140-
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 6, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident abuse, wound care deficiencies, and inadequate Foley catheter care at Rio Grande Rehabilitation and Healthcare Center.
Complaint Details
The complaint investigation substantiated physical abuse of Resident #10 by Resident #11, inadequate wound care and skin assessments for Residents #1 and #2, and failure to monitor and care for Resident #2's Foley catheter, leading to immediate jeopardy.
Findings
The facility failed to protect a resident from physical abuse by another resident, failed to provide appropriate wound care and skin assessments for residents with wounds, and failed to properly monitor and care for a resident with an indwelling Foley catheter, resulting in immediate jeopardy to resident health.
Deficiencies (3)
F 0600: The facility failed to protect Resident #10 from physical abuse by Resident #11, resulting in a fractured femur requiring surgery.
F 0684: The facility failed to complete weekly skin assessments and obtain wound care physician's orders for Residents #1 and #2, resulting in untreated wounds and hospitalizations.
F 0690: The facility failed to provide appropriate Foley catheter care and monitoring for Resident #2, resulting in severe sepsis, respiratory failure, and myocardial infarction requiring ventilator support and intensive care.
Report Facts
Residents reviewed for abuse: 11
Residents reviewed for wound care: 11
Residents reviewed for Foley catheter care: 11
Urine output volume: 300
Urine output volume: 0
Urine drained at hospital: 2000
BIMS score: 12
BIMS score: 0
BIMS score: 8
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding abuse incident, wound care deficiencies, and Foley catheter care failures |
| Director of Nursing | DON | Interviewed regarding wound care policies, Foley catheter care, and staff training deficiencies |
| Certified Nurse Aide #1 | CNA | Interviewed regarding abuse incident and Foley catheter care |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Foley catheter care and nursing responsibilities |
| Medical Director | MD | Interviewed regarding standards of care for quadriplegic residents and Foley catheter monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to protect residents from involuntary seclusion and to provide appropriate person-centered dementia care for residents with dementia-related behaviors.
Complaint Details
The investigation was complaint-driven, focusing on allegations that Resident #2 was subjected to involuntary seclusion and that the facility failed to provide adequate dementia care for residents with behavioral symptoms. The findings substantiated these complaints.
Findings
The facility failed to ensure Resident #2 was free from involuntary seclusion and was improperly sent to her room as punishment for behaviors. The facility also failed to provide appropriate person-centered dementia care interventions for Residents #1 and #2, including inadequate documentation and ineffective behavior management strategies.
Deficiencies (2)
F 0603: The facility failed to protect Resident #2 from involuntary seclusion by sending her to her room as punishment for disruptive behaviors, contrary to facility policy and resident rights.
F 0744: The facility failed to provide appropriate person-centered dementia care and interventions for Residents #1 and #2, including lack of documented interventions for behaviors and ineffective behavior management.
Report Facts
Residents reviewed for dementia care: 7
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding behavior management and use of room confinement |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies on resident disciplinary actions and dementia care plans |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding dementia care training and resident behavior monitoring |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 26, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care, including resident care, medication management, environment safety, staff performance, and vaccination policies.
Findings
The facility had multiple deficiencies including failure to incorporate PASRR recommendations for a resident with serious mental illness, inadequate provision of vision and hearing services, unsafe medication practices, lack of annual performance reviews for nurse aides, improper management of psychotropic medications, failure to provide dental services, and failure to offer pneumococcal vaccination as per CDC guidelines.
Deficiencies (7)
F0644: Facility failed to incorporate PASRR level II recommendations for Resident #31, including psychiatric consultation and correction of inaccurate Huntington's disease diagnosis.
F0685: Facility failed to ensure Resident #40 received necessary hearing devices and Resident #54 had an eye exam as required.
F0689: Facility failed to ensure Resident #26 had a physician's order for medication (icy hot) found at bedside.
F0730: Facility failed to complete annual performance reviews and provide in-service education for four certified nurse aides.
F0758: Facility failed to implement effective behavior monitoring and obtain consents for psychotropic medications for Residents #36, #40, and #49.
F0791: Facility failed to assist Resident #54 in obtaining routine or emergency dental services since admission.
F0883: Facility failed to offer Resident #17 the secondary pneumococcal immunization as recommended by CDC guidelines.
Report Facts
Residents reviewed: 23
Staff reviewed: 4
Psychotropic medications reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding behavior monitoring and resident care |
| RN #1 | Registered Nurse | Interviewed regarding psychotropic medication use and resident behaviors |
| Medical Director | Medical Director | Interviewed regarding PASRR recommendations and resident diagnoses |
| Social Services Director | Social Services Director | Interviewed regarding PASRR process, hearing aids, and psychotropic medication consents |
| Medical Records Director | Medical Records Director | Interviewed regarding scheduling of ancillary appointments and behavior tracking |
| Director of Nursing | Director of Nursing | Interviewed regarding PASRR communication, behavior tracking, consents, and dental services |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding staff performance reviews and facility policies |
| Corporate Social Services Resource | Corporate Social Services Resource | Interviewed regarding PASRR education and ancillary service payment programs |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Nov 20, 2019
Visit Reason
The inspection was conducted based on complaints and allegations related to resident rights, abuse prevention, medication management, facility safety, and regulatory compliance.
Complaint Details
The complaint investigation revealed multiple deficiencies related to resident rights, abuse prevention, medication management, facility safety, and staff training. Several residents were found to be at risk of harm due to inadequate protections and oversight. The facility failed to properly investigate abuse allegations and failed to maintain accessible medical records due to a ransomware attack.
Findings
The facility was found deficient in multiple areas including failure to provide Medicaid/Medicare liability notices, failure to protect residents from abuse, inadequate grievance process, improper use of restraints, failure to investigate abuse allegations, incomplete PASARR referrals, failure to assess residents after falls, unsafe medication storage, incomplete facility assessment, inaccessible medical records due to EMR system hack, poor infection control practices, and inadequate staff training on dementia and abuse prevention.
Deficiencies (15)
F0582: The facility failed to inform four residents of Medicaid/Medicare liability notices and appeal rights in a language they understood and failed to obtain signatures from authorized representatives for cognitively impaired residents.
F0585: The facility failed to inform residents on how and to whom grievances or complaints could be filed and failed to ensure residents had access to grievance information.
F0600: The facility failed to protect seven residents from verbal and physical abuse by other residents and failed to report and investigate these incidents.
F0604: The facility failed to ensure one resident was free from physical restraints by not re-evaluating ongoing use and lacking a comprehensive care plan for the restraint.
F0610: The facility failed to thoroughly investigate abuse allegations involving multiple residents and failed to interview all relevant staff and residents.
F0645: The facility failed to refer two residents to the state-designated authority for level II PASARR evaluation after medication increases and behavioral changes.
F0659: The facility failed to have a registered nurse assess a resident immediately following three unwitnessed falls.
F0689: The facility failed to keep a high fall risk resident's room door open for adequate supervision and failed to maintain proper fall prevention measures.
F0758: The facility failed to discontinue unnecessary psychotropic medication and failed to assess continued use of PRN Lorazepam for a resident.
F0761: The facility failed to ensure all drugs and biologicals were properly stored in the AB hall medication cart, including expired medications and loose tablets.
F0812: The facility failed to ensure proper hand hygiene by food service staff, maintain freezer temperatures below zero degrees Fahrenheit, and remove outdated ready-to-eat food from a resident's room in a timely manner.
F0838: The facility failed to conduct and document a comprehensive facility-wide assessment to determine resources necessary for competent resident care during day-to-day operations and emergencies.
F0842: The facility failed to maintain readily accessible medical records for each resident due to a ransomware attack on the electronic medical records system.
F0880: The facility failed to ensure proper hand hygiene while cleaning residents' rooms and during medication administration.
F0943: The facility failed to provide required dementia management and abuse prevention training to all staff, including RNs, CMAs, and CNAs.
Report Facts
Residents reviewed: 23
Residents affected by abuse: 7
Residents affected by restraint issues: 1
Residents affected by PASARR referral failure: 2
Residents affected by fall assessment failure: 1
Residents affected by medication cart issues: 1
Residents affected by infection control issues: 2
Staff reviewed for training: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding abuse prevention training and medication administration |
| RN #2 | Registered Nurse | Interviewed regarding lack of dementia management training |
| CMA #1 | Certified Medication Aide | Interviewed regarding lack of dementia and abuse prevention training |
| CMA #3 | Certified Medication Aide | Interviewed regarding lack of dementia training and observed medication administration |
| CMA #2 | Certified Medication Aide | Training record reviewed for abuse prevention |
| CNA #6 | Certified Nurse Aide | Interviewed regarding lack of dementia training and infection control observations |
| CNA #1 | Certified Nurse Aide | Interviewed regarding lack of dementia training |
| CNA #2 | Certified Nurse Aide | Training record reviewed for dementia management |
| CNA #8 | Certified Nurse Aide | Interviewed regarding lack of abuse prevention training and infection control observations |
| CNA #5 | Certified Nurse Aide | Training record reviewed for dementia management |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including training, medication, and investigations |
| NHA | Nursing Home Administrator | Interviewed regarding facility assessment, EMR system outage, and multiple deficiencies |
| DM | Dietary Manager | Interviewed regarding food safety and hand hygiene |
| EA #3 | Environmental Aide | Observed and interviewed regarding infection control and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 15, 2018
Visit Reason
The inspection was conducted based on complaints regarding failure to investigate alleged violations, failure to develop and implement effective discharge planning, and failure to provide appropriate dialysis care and communication for residents.
Complaint Details
The complaint investigation focused on allegations of failure to investigate misappropriation of property for Resident #12, failure to ensure safe discharge planning for Resident #7, and failure to provide appropriate dialysis care and communication for Resident #48. The investigation found substantiated deficiencies in these areas.
Findings
The facility failed to timely and thoroughly investigate alleged misappropriation of property for Resident #12, failed to ensure safe discharge planning and education for Resident #7, and failed to report abnormal blood pressures and ensure effective communication with the dialysis center for Resident #48. Deficiencies were noted in investigation procedures, discharge planning, medication education, and dialysis communication.
Deficiencies (4)
F 0610: The facility failed to investigate reported criminal activity against Resident #12 in a timely manner and failed to have evidence the allegation was thoroughly investigated.
F 0660: The facility failed to develop and implement an effective discharge planning process focusing on Resident #7's discharge goals and safe transition to post-discharge care.
F 0684: The facility failed to ensure Resident #48 received treatment and care according to professional standards and the care plan by not reporting abnormal blood pressure to the provider or clarifying orders.
F 0698: The facility failed to ensure effective communication with the dialysis center for Resident #48, as dialysis communication forms were incomplete, risking continuity of care.
Report Facts
Residents reviewed: 19
Blood pressures above systolic 150: 8
Blood pressures above systolic 150: 16
Incomplete dialysis communication forms: 12
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