Durango Health and Rehabilitation

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

A complaint survey, prompted by #CO1933596, #CO2643971 and Incident #2662733 was conducted on 12/8/25 to 12/9/25. One deficiency was cited. Based 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.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 12/8/25, resulting in the deficiency being cited as past noncompliance with a corrective action date of 10/1/25.I. Elopement incident on 9/16/25Resident #1 who was at risk for elopement, required distractions from wandering and structured activities.On 9/16/25 at 12:45 p.m. Resident #1 was observed at the nurses’ station. At approximately 1:00 p.m. a certified nurse aide (CNA) noticed Resident #1 had received a room tray for lunch but the CNA was unable to locate the resident in his bedroom. At approximately 1:13 p.m. the nurse manager notified the interdisciplinary team (IDT) of a potential missing resident. At 1:15 p.m. an overhead page was made regarding the potential elopement of Resident #1. A search was initiated of the building, which included the common areas, rooms, closets, bathrooms, locked areas, the basement, outside areas, storage units, sheds and nearby vicinity around the facility.At approximately 2:25 p.m. the police department was notified of the missing resident. Resident #1 was located on 9/18/25 at approximately 2:00 p.m. He was found within a mile of the facility and had been missing for 49 hours. He was sent to the hospital, where it was noted he had abrasions and needed intravenous (IV) fluids.II. Facility’s plan of correctionThe corrective action plan implemented by the facility in response to Resident #1' s elopement on 9/16/25 was provided by the nursing home administrator (NHA) on 12/8/25 at 12:00 p.m. It revealed in pertinent part:A. Action to correct the deficient practice for Resident #1On 9/16/25, a full house audit of all elopement assessments was reviewed to ensure accuracy and to i..

A compliant survey, prompted by #CO39082 and #CO39083 was conducted on 2/3/25 to 2/4/25. One deficiency was cited. Based 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. Findings include:I. Facility policy and procedureThe Notification of Physician or Responsible Party policy, revised October 2021, was provided by the nursing home administrator (NHA) on 2/5/25 at 10:35 a.m. It read in pertinent part,"It is the policy of this facility to notify the resident, his/her attending physician and/or family/responsible party of changes in the resident' s condition and/or status."Unless otherwise instructed by the resident, the nurse supervisor will notify the resident' s family/responsible party when:The resident is involved in any accident or incident which results in an injury including injuries of an unknown source;There is a significant change in the resident' s physical, mental or psychosocial status;There is a need to alter the resident' s treatment significantly;There is a change in the resident' s room assignment;A decision has been made to discharge the resident from the facility; and/or,It is necessary to transfer the resident to a hospital."Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident' s condition or status."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 11/09/23 and passed away on 12/31/24. According to the December 2024 computerized physician orders (CPO), diagnoses included Parkinson' s disease (neurological disorder) without dyskinesia (involuntary movements) and neurocognitive disorder with Lewy Bodies (neurological disorder/type of dementia).The 11/20/24 minimum data set (MDS) assessment revealed Resident #1 had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15.B. MDPOA..

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility' s general characteristics. This facility consists of two attached, Type V (111) single-story structures, approximately 44,014 sq ft total, with two partial basements and a partial crawl space. The smaller basement is utilized for mechanical equipm.. Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 996.3.4.1.1Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or s.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Fire alarm Semi-Annual: Not Provided2) Fire alarm Sensitivity test (2 Years) (72 14.4.5.3.2): Not ProvidedBased on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Sec.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Generator fuel quality (annually) (110 8.3.8): Not Done2) Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Not DoneNFPA 110 8.3.8 A fuel quality test shall be performed at least annuallyUsing tests approved by ASTM standards.NFPA 110 8.3.7 Storage .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) Fire Doors report (annually)(80 5.2): Not Done2) Clean utility room broken door closure 3) The janitor closet junction wing needs closure to speed up4) need closure put back on sunflower linen closet5) need closure on housekeeping sunflower areaNFPA 101, 8.3.3.1 Openings requir.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) The exit sign for fire door one is not illuminated NFPA 101 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The paint room deemed hazardous needs door closure2) The environmental storage room deemed hazardous requires door closure3) all resident rooms used for storage must have a door closure and are deemed hazardous rooms4) boiler room ceilings need drywall repairsNFPA 101 19.3.2.1.3 The do.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) missing gas cable on kitchen applianceNFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing in.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) A carbon monoxide detector for fuel-fired fireplace is required to be connected to FACPNFPA 101 Heating, Ventilating, and Air Conditioning (101 19.5.2.3(2)(f)): Electrically supervised carbon monoxide detection in accordance with Section 9.8 shall be provided in the room where the firepl..

A recertification survey with complaint #CO36410 and #CO36413 was completed on 6/24/24 to 6/27/24. Twenty-one .. An Emergency Preparedness survey was conducted from 6/24/24 to 6/27/24. One deficiency was cited. Based on interviews and observations, the facility failed to consistently serve food that was palatable, attractive and.. Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional st.. Based on observation and interviews, the facility failed to ensure that professional standards of practice were follow.. Based on observation, record review and interviews, the facility failed to ensure one (#67) of nine residents out of 45.. Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored a.. Based on observations, interviews and record review, the facility failed to ensure one (#50) out of one resident revie.. Based on observations, interviews and record review, the facility failed to ensure one (#57) of six residents reviewed .. Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of ac.. Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the r.. Based on observations, record review and interviews, the facility failed to ensure one (#57) of five residents reviewe.. Based on observations, record review and interviews, the facility failed to maintain an infection control program desi.. Based on observations, record review and interviews, the facility failed to provide necessary respiratory care consist.. Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error r.. Based on record review and interview, the facility failed to conduct two exercises annually to test the facility' s emer.. Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required.. Based on record review and interviews, the facility failed to ensure one (#45) of two residents with limited range of .. Based on record review and interviews, the facility failed to ensure that the personal funds accounts were managed .. Based on record review and interviews, the facility failed to ensure the resident' s right to be informed of, and partici.. Based on record review and interviews, the facility failed to ensure three (#42, #52 and #68) of five residents review.. Based on record review and interviews, the facility failed to inform three (#23, #81 and #82) of three residents revie.. Based on record review and interviews, the facility failed to maintain medical records on each resident that were ac.. III. Resident #67A. Resident statusResident #67, age less than 65 was admitted on 7/27/23. According to the June 20..