Durango Health and Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#13) of five residents received treatment and care in accordance with professional standards or practice out of 48 sample residents. Specifically, the facility failed to:-Complete a timely assessment after Resident #13 experienced altered mental status; and,-Ensure an antibiotic was started in a timely manner for Resident #13.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure residents were kept free from abuse for one (#3) of six residents reviewed for abuse out of six sample residents. Specifically, the facility failed to protect Resident #3 and Resident #4 from physical abuse toward each other.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free of accident hazards for one (#1) of three residents reviewed for accidents/hazards out of three sample residents. Specifically, the facility failed to prevent an elopement for Resident #1 on 9/16/25.

Inspectors wroteBased on record review and interviews, the facility failed to inform the resident or consult with the residents representative regarding a change in the resident's treatment for one (#1) of three residents reviewed out of five sample residents. Specifically, the facility failed to notify Resident #1's medical durable power of attorney (MDPOA) of a medication change.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to ensure food items served were consistent with the posted daily menu.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident's right to be informed of, and participate in his or her treatment for four (#4, #53, #70 and #41) of four residents out of 45 sample residents reviewed for the right to be informed and make treatment decisions. Specifically, the facility failed to inform Resident #4, Resident #53, Resident #70 and Resident #41 and/or their legal representative of the length of time the residents would be in isolation for COVID-19 and when they would be able to leave their rooms.

Inspectors wroteBased on record review and interviews, the facility failed to inform three (#23, #81 and #82) of three residents reviewed for beneficiary notices out of 45 sample residents in a timely manner of changes to their services covered by Medicare. Specifically, the facility failed to: -Ensure Resident #23's Notice of Medicare Non-Coverage (NOMNC) included the last covered day and the appeal information; and, -Ensure Resident #81 and Resident #82 were provided a NOMNC letter upon changes to their Medicare coverage.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for four (#7, #27, #11 and #22) of five residents out of 45 sample residents. Specifically, the facility failed to: -Ensure neurological checks were completed appropriately for Resident #7 following an unwitnessed fall; -Ensure Resident #7's fall care plan was reviewed and new interventions were added following an unwitnessed fall; -Ensure Resident #27 was appropriately assessed for self-administration of a wart removal medication and eye drops; -Ensure a safety assessments was completed for Resident #27 to determine if she was safe to use a hot tea kettle with a heating element in her room; -Ensure a safety assessment was completed for Resident #11 to determine if he was safe to use a space heater in his room; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 10.34%, or three errors out of 29 opportunities for error.

Inspectors wroteBased on interviews and observations, the facility failed to consistently serve food that was palatable, attractive and at a safe and appetizing temperature. Specifically, the facility failed to ensure resident food was served at palatable temperatures.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate; -Ensure housekeeping staff properly sanitized resident rooms; -Dispose of contaminated medication pass water cups; -Offer hand hygiene to residents before meals; and, -Implement an effective water management plan.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of training per year. Specifically, the facility failed to: -Ensure a system was in place to track CNA training to ensure they met the requirements; and, -Ensure CNA #9 and CNA #10 received the required 12 hours of training per year.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the personal funds accounts were managed adequately for two (#2 and #30) of three residents reviewed for personal funds out of 45 sample residents. Specifically, the facility failed to notify Resident #2 and Resident #30, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#42, #52 and #68) of five residents reviewed for abuse out of 45 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #42 from physical abuse by Resident #25; and, -Protect Resident #52 and Resident #68 from physical abuse by Resident #24.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for three (#67, #26 and #29) of nine residents reviewed out of 45 sample residents. Specifically, the facility failed to: -Ensure medications and insulin supplies, including sharps, were not left at the bedside; -Ensure medications were not dispensed and stored in medication cups in a nurse's pocket; and, -Ensure medications were not contaminated by placing dispensed medication back into the original bottle.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one (#57) of six residents reviewed for activities out of 45 sample residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Specifically, Resident #57 was not provided with meaningful activities or one-to-one activity staff visits per her individualized plan of care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#58 and #67) of two sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of 45 sample residents. Specifically, the facility failed to: -Notify the physician for high blood sugar readings for Resident #58; and, -Consistently monitor blood sugars according to the physician's order for Resident #67.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#57) of five residents reviewed for pressure injuries out of 45 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Specifically the facility failed to implement timely interventions to prevent Resident #57 from developing a Stage 2 pressure injury to her right lateral ankle on 5/25/24 and to prevent the potential for further pressure injuries to occur.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#45) of two residents with limited range of motion received appropriate treatment and services out of 45 sample residents. Specifically, the facility failed to offer restorative nursing services as recommended by physical therapy to prevent decline in physical function for Resident #45.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide necessary respiratory care consistent with professional standards of practice in coordination with the resident plan of care for two (#4 and #3) out of four residents reviewed for respiratory care out of 45 sample residents. Specifically, the facility failed to: -Ensure Resident #4 received supplemental oxygen therapy per the physician's orders; and, -Ensure Resident #3 could safely and appropriately perform her tracheostomy care independently.

Inspectors wroteBased on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for three (#57, #58, #11) of three residents reviewed for pain out of 45 sample residents. Specifically, the facility failed to ensure as needed (PRN) pain medications had established parameters for Resident #57, Resident #58 and Resident #11.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#67) of nine residents out of 45 sample residents were free from significant medication errors. Specifically, the facility failed to ensure Resident #67 was administered the correct insulin.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of six medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure medications were properly labeled with open dates; and, -Ensure expired medications were removed from the medication cart and storage rooms.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one (#50) out of one resident reviewed for mechanically altered diets out of 45 sample residents received food prepared in a form designed to meet her needs. Specifically, the facility failed to provide Resident #50 the correct mechanically-altered diet as prescribed.

Inspectors wroteBased on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for one (#78) of one resident out of 45 sample residents. Specifically, the facility failed to ensure Medical Orders for Scope of Treatment (MOST) forms were not destroyed when residents were discharged from the facility.

Inspectors wroteBased on record review and resident interviews, the facility failed to promptly address and attempt to resolve resident group complaints and grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to: -Ensure food was constantly palatable or available as requested; and, -Ensure residents felt their concerns with food temperatures were timely corrected.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a sanitary, orderly, and comfortable homelike environment for residents in the dining room and an outdoor resident door. Specifically, the facility failed to: -Ensure cigarette butts were properly disposed of and not littered on the ground in a resident outdoor space; and, -Ensure residents in the facility were not subjected to a ceiling that leaked water and in poor condition.

Inspectors wroteBased on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#52 and #51) of five residents reviewed for pressure ulcers out of 34 sample residents. Resident #52 was admitted to the facility with intact skin, and no pressure ulcers, and developed multiple areas of skin breakdown to her buttocks, perineal area, heels and ankles. The facility failed to consistently and accurately assess and monitor the resident's skin and provide adequate pressure-relieving interventions. As a result, Resident #52 developed multiple pressure areas, some of which had healed. Her skin breakdown as of 11/11/21 included two unstageable pressure ulcers to her heel, irritated and reddened areas to her thigh from the strap that held her catheter tubing in place, irritation to her nose and ears from her oxygen nasal cannula and tubing. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for two (#38,#72) residents of six residents reviewed for falls and accidents out of 34 sample residents. Resident #38 who had severe cognitive deficits and resided on the facility's memory care unit (MCU), resulting in four falls in four months. One of the falls, which occurred on 8/4/21, resulted in harm to the resident. Due to a deep laceration to her right outer hand, Resident #38 required transport to the local emergency room for stitches. The facility also failed to provide supervision, monitoring and education to staff to prevent Resident #38 from eloping from the MCU's secured patio via a gate on 10/4/21, which led to the resident sustaining another fall in the community while away from the facility. [...]

Inspectors wroteVI. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbances, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. The 9/23/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. He required extensive assistance from two or more persons for bed mobility, transfers, toileting, dressing and personal hygiene. He required extensive physical assistance from one person for locomotion on and off the unit. B. Observations and resident interview Resident #25 was interviewed on 11/9/21 at 8:45 a.m. Resident #25 said he was bored to death. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide food and drinks that were palatable, attractive and served at appetizing temperatures in four of four resident hallways. Specifically, the facility failed to: -Ensure food was prepared in a palatable manner, including over-cooking certain foods, especially meat; -Ensure foods such as green beans were seasoned in a flavorful manner; and -Ensure resident's choices of beverages were being honored.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident was treated with dignity and respect and cared for in a manner and in an environment that promoted maintenance or enhancement of quality of life for three (#58, #65, #17) of six residents reviewed for dignity out of 34 sample residents. Specifically, the facility failed to ensure Residents #58, #65, and #17 were treated with respect and dignity while receiving care from staff.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#69) of two residents reviewed for abuse out of 34 sample residents was kept free from abuse. Specifically, the facility failed to protect Resident #69 from verbal abuse by registered nurse (RN) #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide catheter care in a sanitary manner to prevent infection and promote comfort for one (#52) of one resident reviewed for catheters out of 34 sample residents. Specifically, the facility failed to ensure nursing staff used the proper technique and products in keeping with professional standards when providing indwelling Foley catheter care for Resident #52.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to minimize the risk for foodborne illness in a highly susceptible population in one of one facility kitchen. Specifically, the facility failed to follow industry standards for: -Proper hand hygiene and glove use; -Properly date marking and discarding expired foods; and -Ensuring stored utensils and dishware were dry and clean. Cross reference F802, sufficient and competent dietary support personnel.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure dignified care for seven of seven (#98, #45, #24, #256, #44, #52, and #83) residents reviewed for dignity of 46 sample residents, and several residents who actively participated in resident council. Specifically, the facility failed to: -Ensure residents were spoken to in a dignified, respectful manner; -Provide resident cares with dignity; and -Pass medications in a dignified manner. Residents used words such as rude, condescending, undignified and hateful to describe how some staff treated them. Residents said as a result they felt, as stated in their words, bad, angry, invisible, weird, and like I'm nobody.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to honor bathing, food and snack preferences for one (#256) of two residents reviewed for choices, and for residents who resided on the secured unit and main living area of the facility, out of 46 sample residents. Specifically, the facility: -Failed to offer and provide bathing opportunities for Resident #256; and -Failed to offer and provide food and snack preferences for the residents who resided on the secured unit and main living area of the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure safe narcotic and vaccine storage for four of six medication carts and two of two medication storage refrigerators. Specifically, the facility failed to: -Ensure double locking of schedule II narcotics; and -Store vaccines in a non-dormitory style refrigerator.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to employ sufficient dietary support staff to carry out the functions of the food and nutrition services department in one of one facility kitchen. Specifically, insufficient numbers of adequately trained food and nutrition staff contributed to prolonged wait times for meals and overall decreased resident satisfaction with dining. Cross reference F804, food palatability.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently provide palatable foods for 10 (#45, #49, #73, #64, #24, #12, #37, #98, #91, #90) of 46 sample residents, residents who participated in resident council, and potentially all facility residents. Cross reference F802, sufficient dietary support staff.

Inspectors wroteBased on record review and interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical record for one (#305) of one resident reviewed for advanced directives of 46 sample residents. Specifically, the facility failed to ensure the current physician orders (CPO) for Resident #305's code status accurately reflected the resident's choices for advanced directives.

Inspectors wroteBased on record review and interviews, the facility failed to ensure timeliness of minimum data set (MDS) assessments for one (#2) of two residents reviewed of 46 sample residents. Specifically, more than 120 days elapsed since Resident #2's most recent quarterly MDS.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a preadmission screening/resident review (PASRR) Level II screen was completed for one (#17) of one resident reviewed for PASRR of 46 sample residents.

Inspectors wroteBased on record review and interviews, the facility failed to honor the residents' right to participate in the development and implementation of the person centered care plan process for two (#12 and #64) of two residents reviewed for participation in care planning of 46 sample residents. Specifically, the facility: -Failed to invite Resident #12 and #64 to their care planning conferences; and -Failed to hold quarterly care conferences for Resident #12.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide services to meet professional standards of quality, affecting two (#44 and #73) of nine residents reviewed for medication administration of 46 sample residents. Specifically, the facility failed to ensure medications were handled in a sanitary manner during preparation for Residents #44 and #73.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adequate supervision to ensure freedom from falls and accidents for two (#40 and #89) of five residents reviewed for accidents and hazards of 46 sample residents. Specifically, the facility failed to ensure thorough and timely interventions to prevent falls for Resident #89. The facility failed to thoroughly assess and implement all possible fall interventions for Resident #89 in a timely manner, which included using a male certified nurse aide (CNA) for Resident #89's cares, moving the resident closer to the nurses' station to assist with frequent rounding in a timely manner, and ensuring appropriate footwear was maintained consistently. As a result, Resident #89 sustained 13 falls within the previous two months, five falls within the previous week. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain acceptable parameters of nutritional status for one (#12) of five residents reviewed for nutrition out of 46 sample residents. Specifically, the facility failed to: -Adequately assess, monitor, and address the nutritional needs for Resident #12; -Obtain Resident #12's weight when he was readmitted to the facility; and -Identify and assess a weight loss of 8.76 percent (%) over a six-month period for Resident #12.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 7.69%, or two errors out of 26 opportunities for error.