Rehabilitation and Nursing Center of the Rockies

Resident Assessment and Care Planning Deficiencies

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

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

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 choose his or her attending physician.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Egress Deficiencies

Have exits that are accessible at all times.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Resident Assessment and Care Planning Deficiencies

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

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper power supply for life support equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the backup emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110.This was evidenced by the following:1. No records or documentation for generator annual fuel testing.2. No records or documentation for generator annual load bank testing. NFPA 110, 8.3.1 A fuel quality test shall be performed annually using tests approved by ASTM standards.NFPA 110, 8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. This deficiency has the potential to affect all occupants, including staff, residents, and visitors, should the generator fail to start during an emergency. This was discussed during the record review and again during the exit conference. Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) NFPA 101, NFPA 13, 8.15.1.2.18.1, and NFPA 25, 5.3.3.1.This was evidenced by the following.1. North exterior roof overhangs appear to be combustible material that exceeds 4 feet and requires sprinkler protection.2. Missing quarterly flow testing reports.NFPA 13, 8.15.1.2.18.1 Combustible soffits, eaves, overhangs, and decorative frame elements shall not exceed 4 ft 0 in. (1.2 m) in width. NFPA 25, 5.3.3.1 Mechanical waterflow alarm devices, including but not limited to water motor gongs, shall be tested quarterly. This deficiency could affect all residents, staff, and visitors should the roof overhang is not protected by fire sprinklers. This was discussed during the exit conference. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on July 21, 2025, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19 “Existing Health Care Occupancies.”This structure is a one (1) story, Type V (000) construction. This original facility was constructed in 1963. The facility is licensed for 106 beds, and the census on the date of the survey was 89.The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. This facility is classified as fully sprinklered.The results of this survey were discussed with the Administrator and the Maintenance Director during the exit conference.

Based 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 se.. Based on observations, record review and interviews, the facility failed to investigate thoroughly allegations of staff-to-resident verbal abuse and failed to initiate a thorough investigation of an injury of an unknown origin. The facility failure affected two (#24 and #4) of five residents out of 37 total sample residents. 1. The facility failed to recognize, address, and thoroughly investigate allegations of staff-to-resident abuse. Interview with Resident #24, who was visibly tearful during three interviews, one on 6/23/25, and two on 6/24/25, r.. *** CITATION TEXT NOT FOUND *** A licensure survey with complaint #CO40572 was completed on 6/23/25 to 6/26/25. Two deficiencies were cited. .. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Based 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. .. Based 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 infe.. Based 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... Based on observations, record review and interviews, the facility failed to investigate thoroughly allegations of staff-to-resident verbal abuse and failed to initiate a thorough investigation of an injury of an unknown origin. The fa.. Based 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 n.. Based 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.. Based 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 high.. Based 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.. Based 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 .. Based 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 reside.. Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. .. *** CITATION TEXT NOT FOUND *** A recertification survey with complaint #CO39939 and #CO40451 was completed on 6/23/25 to 6/26/25. Eleven deficiencies were cited... An Emergency Preparedness survey was conducted from 6/23/25 to 6/26/25. No deficiencies were cited. .. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally