Rehabilitation and Nursing Center of the Rockies

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure services met professional standards of practice for one (#9) of eight residents out of 13 sample residents. Specifically, the facility failed to:-Ensure nurses did not leave medications on Resident #9's bedside table; -Ensure Resident #9 when he was administered his medications to make sure he swallowed them; and; -Ensure nurses did not document in Resident #9's medication administration record (MAR) that the resident's medications were administered/swallowed when they were not.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#5) of eight residents reviewed for medical record accuracy out of 13 sample residents. Specifically, the facility failed to ensure accurate documentation of Resident #5's medication administration for Cardura (medication used to treat high blood pressure).

Inspectors wroteIV. Resident #4 - The facility failed to initiate a thorough investigation of an injury of unknown origin. A. Resident #4 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included systemic involvement of connective tissue (autoimmune disease), arthritis, edema, and history of stroke. The 6/3/25 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 14 out of 15. The resident required total assistance (fully dependent) from the staff for toileting, dressing, bed mobility (the ability to sit up or roll from side to side while lying), and all transfers. The resident required (two-person) extensive assistance from the staff for bathing and personal hygiene. Resident #4 had impairments to her lower extremities and a limited full range of motion. 2. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#4 and #207) of eight residents reviewed for accident hazards received adequate supervision out of 37 sample residents. Resident #4 was admitted to the facility for long term care on 4/5/24 with diagnoses of systemic involvement of connective tissue (autoimmune disease), arthritis, edema and history of stroke. Resident #4 was identified as cognitively intact and was able to transfer with a sit-to-stand mechanical lift (a lift device used to enhance a resident's dignity and independence by helping residents who can bear weight and participate to transition from a seated to a standing position). Resident #4 said a male certified nurse aide (CNA) transferred her without utilizing the sit-to-stand mechanical lift in May 2025. She said while the CNA was transferring her, they heard a pop. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and follow up with residents on the outcomes and resolutions of grievances expressed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#52) of five residents had the right to choose her own attending physician out of 37 sample residents. Specifically, the facility failed to allow Resident #52 to choose their primary care provider (PCP) when the resident's previous primary care provider stopped seeing residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#207 and #21) of five residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 37 sample residents. Specifically, the facility failed to: -Ensure Resident #21's behavior care plan had resident specific behaviors and triggers identified; -Document consistent behaviors for Resident #207 and Resident #21 to justify the continued use of psychotropic medications; and, -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions, for Resident #207 and Resident #21's psychotropic medications.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient discharge preparation and documentation for one (#99) of three residents reviewed for a safe and orderly discharge out of 37 sample residents. Specifically, the facility failed to ensure thorough documentation, including physician notification, when Resident #99 and her representative left the facility against medical advice (AMA).

Inspectors wroteBased on record review and interviews, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#21) of five residents reviewed for PASRR out of 37 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR Level II notice of determination (NOD) for Resident #21.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#78) of five residents reviewed for activities out of 37 sample residents received an ongoing program of activities designed to meet their needs and interests, and promote physical, medical, and psychosocial well-being. Specifically, the facility failed to offer and provide a personalized activity program for Resident #78.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#23) of five residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 37 sample residents. Specifically, the facility failed to identify Resident #23 had a history of suicidal ideation in order to monitor for worsening signs and symptoms of depression or suicidal ideation.

Inspectors wroteBased on record review and interviews, the facility failed to ensure facility resources were administered in a manner that allowed its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. Specifically, the facility failed to: -Provide sufficient leadership to address and or avoid multiple concerns; -Prevent, report and fully investigate allegations of abuse timely to provide immediate protections to residents at risk; -Report and investigate an injury of unknown origin in a timely manner so that an accurate timeline of events could be established and the injury could be effectively treated and monitored; and, -Monitor a resident for worsening symptoms of depression who expressed suicidal ideations.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeeping staff performed appropriate hand hygiene between cleaning resident rooms; -Ensure staff kept clean and soiled laundry separate in the laundry room; -Ensure staff handled plastic drinking cups in a hygienic manner to prevent contamination; and -Provide tracheostomy care for Resident #34 in a sanitary manner; and, -Ensure that Resident #95's urinary catheter drainage bag was cleaned appropriately and stored in a sanitary manner.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for three (#3, #12 and #9) of four residents out of 20 sample residents. Specifically, the facility failed to ensure Resident #3, #12 and #9 received timely person-centered assistance with meal set up and/or eating.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision during use of assistive devices to keep residents free from safety hazards for two (#10 and #11) of three residents out of 20 sample residents. Specifically, the facility failed to ensure wheelchair pedals were attached to Resident #10's and Resident #11's wheelchairs prior to pushing the residents within the facility. I. Facility policy and procedure The Fall Management System policy, reviewedNovember 2023, was received from the director of nursing (DON) on 10/22/24 at 4:55 p.m. The policy read in pertinent part, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#2) of three residents out of nine sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure identified person-centered fall interventions, which were care planned, were implemented consistently for Resident #2 following a fall with a left wrist fracture.

Inspectors wroteBased on record review and interviews, the facility failed to manage the pain of two (#7 and #8) of three residents out of nine sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to ensure pain medication had documented parameters for Resident #7 and Resident #8.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#65) of one resident reviewed for respect and dignity out of 40 sample residents. Specifically, the facility failed to: -Ensure Resident #65 was treated with respect and dignity from facility staff after she reported concerns; -Ensure Resident #65 was offered alternative activities when facility administration requested she not enter the activities hallway; -Ensure Resident 65's care plan was updated to with her involvement, included accurate resident needs and interventions; and, -Ensure Resident #65's concerns and interventions were documented in her medical record.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (#74) of one resident reviewed for dementia care out of 40 sample residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop a comprehensive plan of care, to include person-centered interventions to engage Resident #74 and address his wandering behaviors.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for convenience and were not required to treat medical symptoms for one (#39) of one resident reviewed for restraints out of 31 sample residents. Specifically, the facility failed to: - perform an initial assessment and subsequent quarterly assessments for the use of a lap belt, - obtain a physician's order with a specific medical diagnosis for the use of a lap belt, - obtain a consent from the resident's medical durable power of attorney (MDPOA) prior to the use of a lap belt, - develop a monitoring system for the safe utilization of a lap belt, and - develop a care plan to reflect the interventions that address not only the immediate medical symptoms, but the underlying problems that might be causing the symptoms. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide services that met professional standards of quality according to accepted standards of clinical practice for one (#2) of one resident reviewed for care and services out of 31 sample residents. Specifically, the facility failed to follow physician orders for notification of weight gain with parameters which lead to a possible delay in treatment.