Inspection Reports for
River Valley Rehabilitation Healthcare Center
1335 6TH ST, DEL NORTE, CO 81132-3201, CO
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 2
Date: Apr 2, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with food safety and sanitation standards in the main kitchen and dining room.
Findings
The facility failed to store, prepare, distribute, and serve food in a sanitary manner, including failure to label, date, and discard food timely, and failure to clean the refrigerator and hot cocoa machine regularly.
Deficiencies (2)
F 0812: The facility failed to ensure food was labeled, dated, and discarded in a timely manner, with multiple food items found without open dates and some expired items in the refrigerator.
F 0812: The facility failed to maintain a sanitary kitchen, with an unclean refrigerator bottom and a dirty hot cocoa machine in the main dining room.
Report Facts
Expired food items: 2
Undated food items: 8
Food storage duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food labeling, storage, and cleaning deficiencies. | |
| Nursing Home Administrator | Interviewed regarding food safety practices and corrective actions. |
Inspection Report
Routine
Deficiencies: 10
Date: Dec 19, 2024
Visit Reason
Routine inspection of River Valley Rehabilitation and Healthcare Center to assess compliance with regulatory requirements including resident care, medication administration, abuse prevention, and infection control.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity by ensuring call lights were within reach, failure to protect a resident from verbal abuse by a staff member, failure to ensure qualified staff properly handled physician orders, failure to provide appropriate assistance with activities of daily living, failure to follow physician orders for pain management and dressing changes, failure to complete nurse aide performance reviews, medication errors including improper insulin pen priming, failure to accommodate resident food preferences, failure to maintain sanitary food preparation practices, and failure to properly disinfect glucometers.
Deficiencies (10)
F 0550: The facility failed to ensure call lights were within reach for four residents (#3, #39, #49, #51), compromising their dignity and ability to call for assistance.
F 0600: The facility failed to protect Resident #53 from verbal abuse by CNA #7, who was terminated following the incident.
F 0659: The facility failed to ensure qualified staff properly received, entered, confirmed, and revised physician orders; a medical records assistant (CNA) was improperly confirming orders.
F 0677: Resident #5 was not provided appropriate assistance for transfers and positioning per therapy recommendations, resulting in unsafe transfers and skin tears.
F 0684: Resident #4 did not receive prescribed lidocaine patches for 18 days without provider notification and had missed dressing changes without documentation of wound healing notification.
F 0730: The facility failed to complete performance reviews and provide in-service education for CNAs #2 and #4 within the past 12 months.
F 0759: RN #1 failed to prime the insulin pen correctly before administering insulin to Resident #13, resulting in a medication error; Resident #44 did not receive correct dose of aripiprazole due to unavailable medication.
F 0806: The facility failed to provide food choices according to Resident #12's preferences, including lack of grapes which the resident requested repeatedly.
F 0812: Food service staff failed to perform proper hand hygiene and glove changes during food preparation and serving in the main kitchen.
F 0880: The facility failed to properly clean and disinfect glucometers between resident uses, not following manufacturer's two-wipe and two-minute wet contact time recommendations.
Report Facts
Medication error rate: 5.88
Residents affected by dignity deficiency: 4
Residents affected by abuse deficiency: 1
Residents affected by qualified staff deficiency: 11
Residents affected by ADL assistance deficiency: 1
Residents affected by pain management deficiency: 1
CNAs without performance review: 2
Medication errors observed: 2
Residents affected by food preference deficiency: 1
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Named in verbal abuse finding involving Resident #53. |
| RN #1 | Registered Nurse | Named in insulin administration medication error. |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Interviewed regarding pain management and medication availability for Resident #4. |
| CNA #3 | Certified Nurse Aide | Interviewed regarding Resident #53 abuse incident and Resident #5 care. |
| PTA | Physical Therapy Assistant | Interviewed regarding Resident #5 transfer and positioning needs. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication orders, abuse, and care plans. |
| NHA | Nursing Home Administrator | Interviewed regarding multiple deficiencies including abuse investigation and medication administration. |
| DM | Dietary Manager | Interviewed regarding food preferences and kitchen hygiene. |
| CK #1 | Cook | Observed failing to perform proper hand hygiene and glove changes in kitchen. |
| RDDSC | Regional Director of Dietary Services Consultant | Interviewed regarding kitchen hygiene practices. |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, abuse prevention, medication administration, dietary services, and infection control at River Valley Rehabilitation and Healthcare Center.
Findings
The facility failed to ensure residents' call lights were within reach, protect a resident from verbal abuse by a staff member, follow physician orders for pain medication and dressing changes, provide food according to resident preferences, and maintain proper infection control practices for glucometer cleaning.
Deficiencies (5)
F 0550: The facility failed to ensure call lights were within reach for four residents (#3, #39, #49, #51), despite care plans and staff responsibility to maintain accessibility.
F 0600: The facility failed to protect Resident #53 from verbal abuse by CNA #7, who used expletives and forced the resident to shower against his will.
F 0684: The facility failed to follow physician orders for Resident #4's pain medications and dressing changes, including not administering lidocaine patches for 18 days and missing dressing changes without provider notification.
F 0806: The facility failed to provide food choices according to Resident #12's preferences, notably lacking grapes which the resident requested and dietary staff failed to substitute.
F 0880: The facility failed to properly clean and disinfect glucometers, as RN #1 used only one wipe and did not allow the required two-minute wet contact time between uses.
Report Facts
Residents reviewed for dignity and respect: 41
Residents affected by call light deficiency: 4
Residents reviewed for abuse: 41
Residents affected by abuse deficiency: 1
Days lidocaine patch not administered: 18
Dressing changes missed: 3
Residents sampled for infection control: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Named in verbal abuse finding involving Resident #53 |
| RN #1 | Registered Nurse | Named in infection control finding related to glucometer cleaning |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Interviewed regarding medication administration deficiencies for Resident #4 |
| Director of Nursing | Director of Nursing | Interviewed regarding call light accessibility and medication administration |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding multiple deficiencies including abuse, medication, and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding dietary/snack deficiencies for Resident #12 |
Inspection Report
Routine
Deficiencies: 13
Date: Jul 13, 2023
Visit Reason
Routine inspection of River Valley Rehabilitation and Healthcare Center to assess compliance with regulatory standards including abuse prevention, restraint use, infection control, medication management, and resident care.
Findings
The facility had multiple deficiencies including failure to prevent and properly investigate resident abuse, inadequate restraint use documentation and orders, failure to provide meaningful activities, improper pressure ulcer care, unsafe transfer practices, inadequate fall prevention measures, improper respiratory care, incomplete staff competencies and training, medication labeling and storage issues, deficient hospice service coordination, and lapses in infection control practices.
Deficiencies (13)
F0600: The facility failed to prevent resident to resident abuse and physical abuse by a family member, and failed to properly substantiate abuse investigations for three residents.
F0604: The facility failed to comprehensively assess and care plan the continued use of personal alarms and wander guards as potential restraints for three residents, lacking physician orders and consents.
F0686: The facility failed to provide appropriate pressure ulcer care for one resident, lacking timely measurement, documentation, care planning, and Braden scale assessment.
F0689: The facility failed to provide adequate supervision and safe transfer assistance for three residents, resulting in falls and injuries, and failed to ensure proper use of mechanical lifts and two-person transfers.
F0695: The facility failed to ensure proper respiratory care for two residents, including administering oxygen per physician orders and having required physician orders for continuous oxygen use.
F0726: The facility failed to complete required competencies for three certified nurse aides, two licensed practical nurses, and two registered nurses as identified in the facility assessment.
F0730: The facility failed to complete annual performance reviews and provide in-service education based on reviews for three certified nurse aides.
F0758: The facility failed to ensure three residents were free from unnecessary psychotropic medications, lacking behavior monitoring, consents, and physician evaluations for PRN medication extensions.
F0761: The facility failed to ensure drugs and biologicals were labeled and stored properly, including undated opened inhalers and tuberculin vials, expired insulin pen, and unknown pills in medication carts.
F0812: The facility failed to ensure cutting boards in the kitchen were free from deep scratches and stains, posing a risk for bacterial growth.
F0849: The facility failed to ensure hospice services met professional standards, lacking a written agreement including hospice plan of care, and failed to provide orientation to hospice staff.
F0880: The facility failed to maintain an infection control program, failing to offer residents hand hygiene before meals and failing to follow proper hand hygiene standards during dining service.
F0947: The facility failed to ensure certified nurse aides received annual dementia management and abuse prohibition training.
Report Facts
Residents reviewed for abuse: 21
Residents reviewed for physical restraints: 21
Residents reviewed for accident hazards: 21
Residents reviewed for psychotropic medications: 21
Residents reviewed for hospice services: 21
Residents reviewed for infection control: 21
Residents reviewed for CNA training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Interviewed regarding resident behaviors and lack of knowledge of behavior interventions |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding resident behaviors and psychotropic medication requirements |
| NHA | Nursing Home Administrator | Interviewed regarding facility policies, deficiencies, and follow-up plans |
| DON | Director of Nursing | Interviewed regarding facility policies, deficiencies, and follow-up plans |
| CNA/MA #1 | Certified Nurse Aide with Medication Authority | Interviewed regarding resident behaviors and medication administration |
| CNA #7 | Certified Nursing Assistant | Interviewed regarding unsafe transfer of Resident #4 |
| OT | Occupational Therapist | Interviewed regarding transfer safety and resident assessments |
| DA #3 | Dietary Aide | Interviewed regarding hand hygiene practices |
| CNA #9 | Certified Nursing Assistant | Interviewed regarding hand hygiene practices |
| HD | Hospice Director | Interviewed regarding hospice services and coordination |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Date: Jan 24, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding failure to obtain physician orders for use of alarms and restraints, inappropriate medication management, and inadequate nurse aide training.
Complaint Details
The complaint investigation focused on failure to obtain physician orders for alarms and restraints, inappropriate psychotropic medication management, and inadequate nurse aide training. The findings substantiated these issues with minimal harm or potential for actual harm to residents.
Findings
The facility failed to obtain physician orders for alarms used for residents' safety, did not provide individualized non-pharmacological interventions or timely reassess psychotropic medication needs, and failed to ensure nurse aides completed required annual in-service training including dementia care and abuse prevention.
Deficiencies (3)
F0658: The facility failed to obtain physician orders prior to placing wheelchair and bed alarms for Residents #22 and #33, violating professional standards of care.
F0758: The facility failed to provide individualized non-pharmacological interventions and timely reassessment of psychotropic medication for Resident #22, resulting in unnecessary medication use.
F0947: The facility failed to ensure five certified nurse aides completed at least 12 hours of annual in-service training including dementia management and abuse prevention.
Report Facts
Census: 40
Residents with behavioral healthcare needs: 16
Residents with dementia: 14
Residents with psychiatric diagnoses: 5
Sample residents reviewed: 22
Certified nurse aides reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to obtain physician orders and medication management | |
| Assistant Nursing Home Administrator | Provided records and interviewed regarding facility policies and training | |
| Social Service Director | Interviewed regarding behavioral health services for Resident #22 | |
| Certified Nurse Aides #1, #2, #3 | Interviewed regarding in-service training attendance and knowledge |
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