River Valley Rehabilitation and Healthcare Center

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

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

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Resident Rights Deficiencies

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

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

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

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

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

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

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

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

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

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

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.

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.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Assessment and Care Planning Deficiencies

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

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Provide properly protected cooking facilities.

A complaint survey, prompted by #CO39224 and Incident #39465 and Incident #39675 was conducted on 4/2/25. One deficiency was cited. Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and the main dining room. Specifically, the facility failed to:-Ensure food was labeled, dated and discarded in a timely manner; and-Ensure the refrigerator and hot cocoa machine was cleaned regularly. I. Failed to ensure food was labeled, dated and disposed of timely A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/2/25 read." in pertinent part,"A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request." (Chapter 3-29)B. Observations and interviewsOn 4/2/25 at 12:40 p.m., during the kitchen tour, the following items were found in the main kitchen refrigerator without an open date:-An open container of coleslaw;-A sealed bag of unknown meat;-A plastic container of peaches;-A large sealed storage bag with a red sauce;-A sealed storage bag with a half an avocado;-A large sealed storage bag of celery;-A plastic container of dressing; and-Two packages of muffins. Also observed in the refrigerator were two items that were expired:-A ..

STANDARD not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. During the survey record review, no documentation was available to indicate that the fire alarm system had been tested semiannually in the past year.2012 Life Safety Code 101 section 9.6.1.5*To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff, and visitors throughout the facility if the fire alarm system fails to operate if a fire event was to occur. The initial comments (ID Prefix Tag #K000) are informational only, and are 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). Life safety features that met the requirements at the time of licensure or certification shall be maintained and not be diminished. This facility, licensed for 60 beds, is a one-story, Type II (111) structure without a basement. This facility is fully protected by a National Fire Protection Association (NFPA) Type 13 automatic fire sprinkler system. This survey, conducted on January 16, 2025 was inspected for compliance to fire safety requirements contained in Chapter 19 of the 2012 edition of NFPA 101-Life Safety Code and 2012 edition of NFPA 99-Standard for Health Care Facilities.

A recertification survey with complaint #CO38208, #CO38390, #CO38491, #CO38631 and Incident #38656 was completed on 12/16/24 to 12/19/24. Eleven deficiencies were cited. An Emergency Preparedness survey was conducted from 12/16/24 to 12/19/24. One deficiency was cited. Based on observations, record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures based on the emergency plan that identified the provision of subsistence needs.. Based on observations, record review and interview, the facility failed to ensure one (#4) of three residents out of 41 sample residents received treatment and care in accordance with professional standards of practice and the compre.. Based on observations, record review and interviews, the facility failed to ensure meals were served according to the resident' s preferences for one (#12) of two residents out of 41 sample residents. Specifically, the facility failed to off.. Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent.Specifically, the facility' s medication error rate was 5.88% with two errors out of 34 opport.. Based on observations, record review and interviews, the facility failed to ensure the residents were free from significant medication errors for one (#13) of seven residents reviewed for medication errors out of 41 sample reside.. Based 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 prevent the development and transmission of di.. Based on observations, record review and interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to ensure hand hygiene was conducted appropria.. Based on observations, record review and interviews, the facility failed to promote and maintain the resident' s dignity for four (#3, #39, #49 and #51) of five residents reviewed for dignity and respect out of 41 sample residents.Specifica.. Based on observations, record review and interviews, the facility to ensure for one (#5) of three residents reviewed for assistance with activities of daily living (ADL) out of 41 sample residents received the appropriate treatment and serv.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two .. Based on record review and interviews, the facility failed to ensure residents received care from qualified employees for 11 (#15, #5, #46, #49, #34, #6, #19, #262, #45, #47 and #24) of 11 residents out of 41 sample residents.Specificall.. Based on record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation for one (#53) of three residents reviewed for abuse out of 41 sample residents.Specifically, the facil..