DURANGO, CO - Federal inspectors cited Durango Health and Rehabilitation for medication errors and dietary failures during a June 2024 inspection, including administering the wrong type of insulin to a diabetic resident and serving inappropriate food consistency to a Parkinson's patient for months.
Incorrect Insulin Administered to Diabetic Resident
On June 25, 2024, at 4:41 p.m., an assistant director of nursing prepared and administered insulin to a resident with dangerously high blood sugar. When the nurse checked the resident's glucose level, the meter displayed "high," indicating the blood sugar exceeded 600 milligrams per deciliter.
According to the physician's order, the resident should have received insulin lispro (Humalog) from a pen injector. This rapid-acting insulin begins working within approximately 15 minutes and is designed for quick blood sugar control. Instead, the nurse administered Humulin R insulin from a vial—a fundamentally different medication.
The distinction between these two insulin types creates significant clinical implications for diabetes management. Insulin lispro acts rapidly, with effects beginning around 15 minutes after injection and lasting two to four hours. Humulin R, classified as short-acting insulin, takes approximately 30 minutes to become effective and continues working for three to six hours.
When the facility's consulting pharmacist reviewed the incident, he confirmed this constituted a medication error. The different onset times and duration of action between these insulin formulations mean the resident did not receive the appropriate medication for her condition at that critical moment.
The assistant director of nursing later explained that the resident's insurance would not cover the prescribed insulin pens, so the facility substituted Humulin R from a vial. However, the physician was never notified to change the order, and the substitution occurred without proper authorization. The director of nursing confirmed during her June 27 interview that the wrong insulin had been administered.
Lactose-Intolerant Resident Given Dairy Without Medication
On June 26, 2024, at 8:59 a.m., inspectors observed a registered nurse preparing medications for a lactose-intolerant resident. The resident had a physician's order for Lactaid 3000 units to be taken by mouth, which allows individuals with lactose intolerance to digest dairy products by providing the enzyme their bodies lack.
The nurse could not locate the correct dose of Lactaid in her medication cart. Despite this, she proceeded to mix the resident's other medications in yogurt—a dairy product—and gave him the entire container to eat with breakfast. She stated she would search for the correct Lactaid dose in other medication storage areas.
By 10:45 a.m., the nurse had contacted the resident's physician and obtained a new order changing the Lactaid dose to 9000 units, which the facility had available. She then administered this dose to the resident. However, the medication was not given at the appropriate time according to manufacturer guidelines, which recommend taking Lactaid immediately before consuming dairy products for maximum effectiveness.
The director of nursing later confirmed that the Lactaid order should have been updated earlier and that the medication had not been administered at the correct time. She acknowledged the resident should not have received dairy products when his Lactaid had not been given.
Thyroid Medication Given 90 Minutes Late After Breakfast
During the same morning medication observation, inspectors documented that an assistant director of nursing administered levothyroxine to a resident at 9:05 a.m. The medication was scheduled for 7:30 a.m., making it 90 minutes late—and critically, it was given after the resident had already eaten breakfast.
Levothyroxine is a thyroid hormone replacement medication prescribed for hypothyroidism. The timing of this medication is medically significant because specific foods can interfere with its absorption when consumed together. Medical guidelines recommend taking levothyroxine on an empty stomach for optimal effectiveness.
The facility's consulting pharmacist explained that taking levothyroxine after eating could affect the medication's absorption and reduce its therapeutic benefit. He confirmed it was recommended to take the medication on an empty stomach, making the delayed administration after breakfast problematic for the resident's thyroid management.
Parkinson's Patient Served Wrong Diet for Months
Perhaps one of the most persistent issues documented during the inspection involved a 79-year-old resident with Parkinson's disease who received pureed food for months when she was prescribed a more normal diet consistency.
According to the resident's February 2024 speech therapy discharge summary, she scored a six out of seven on the dysphagia outcome and severity score, indicating only mild swallowing difficulty. The speech-language pathologist recommended a dysphagia advanced diet consisting of soft, tender, moist, and bite-sized foods no larger than 1.5 centimeters. The physician's order documented in June 2024 specified "dysphagia advanced texture."
However, when inspectors observed the resident's meals on June 24 and June 25, she consistently received pureed food. On June 24 at 10:59 a.m., her breakfast plate contained pureed items. On June 25 at 6:33 p.m., her dinner included whole spaghetti noodles with small shrimp pieces, but the green vegetables, dinner roll, and orange dessert were all pureed.
When inspectors checked the resident's meal ticket on June 27, it incorrectly indicated she was prescribed a "dysphagia mechanical soft diet" rather than the dysphagia advanced diet ordered by her physician.
The resident herself expressed frustration during interviews. "The facility mashed all of my food," she told inspectors on June 24. "The flavor was not good and had no taste." She said the facility ground and mashed everything despite having no history of choking.
The speech-language pathologist who originally evaluated the resident confirmed during her June 27 interview that when she discontinued therapy on February 12, 2024, the resident's food did not need to be pureed. She explained that dysphagia advanced diet consists of naturally soft and bite-sized foods such as soft cut-up vegetables, meat that is relatively easy to chew, and mashed potatoes—not pureed items.
The dietary consultant stated that the meal ticket system showed the resident's diet changed on May 5, 2024, but acknowledged this was not an actual physician's order. She said dietary changes required proper requisition forms and expressed confusion about how the resident's diet profile changed without going through proper channels.
This error meant the resident received unnecessarily modified food that affected her meal enjoyment and quality of life for an extended period.
Menu Inconsistencies and Temperature Problems
Federal inspectors documented that food items served did not consistently match the posted daily menu, and room temperature meals failed to meet acceptable standards.
On June 24, 2024, the dinner menu listed shrimp scampi, spaghetti noodles, sauteed asparagus cuts, Italian herbed dinner roll, and chilled peach parfait. What residents actually received was plain spaghetti noodles topped with thick white sauce, cooked shrimp, and snow peas. The sauteed asparagus or alternative sauteed green beans were not available.
The dietary manager acknowledged she added cream to the shrimp scampi recipe, which was not listed in the facility's standardized recipe. She said the previous kitchen manager had instructed her to do this. However, residents and staff were not informed about the cream addition, and the dietary manager admitted she had not considered complications for residents who did not prefer or could not consume dairy products.
During the June 25 lunch service, the menu indicated broccoli florets would be served, but residents received green beans instead. Multiple residents confirmed they had not requested this substitution.
Temperature testing revealed significant problems with room tray service. A test tray plated in the kitchen at 6:10 p.m. was delivered to the unit at 7:20 p.m. Temperature readings showed spaghetti noodles at 123 degrees Fahrenheit, snow peas at 109 degrees, and shrimp scampi at 112 degrees—all below the acceptable temperature of 135 degrees for hot foods.
The dietary manager explained that food carts used for room trays were not heated, and heated plates used in the kitchen were not successful in keeping food at appropriate temperatures throughout the extended delivery time.
Expired Medications Found in Storage Areas
Inspectors identified expired medications in multiple locations throughout the facility during their June 27 observations. In the medication storage room on the Sunflower hallway, they found a multivitamin bottle that expired in October 2023, vitamin B12 that expired in October 2023, loperamide that expired in January 2024, spironolactone that expired February 21, 2024, omeprazole that expired April 19, 2024, and furosemide that expired February 21, 2024.
Expired medications pose risks to resident safety because they can lose effectiveness over time. According to the U.S. Food and Drug Administration, expired medical products can become less effective or risky due to changes in chemical composition or decreases in strength. Certain expired medications face risks of bacterial growth, and medications that have lost potency can fail to treat conditions appropriately.
Staff acknowledged the expired medications should have been removed. A registered nurse stated she would place the expired items in the drug disposal container, and a licensed practical nurse said he would dispose of expired isopropyl alcohol found in a medication cart.
Infection Control Lapses Documented
Federal inspectors observed housekeeping staff failing to follow proper sanitation procedures during room cleaning. On June 26, a housekeeper began cleaning by spraying disinfectant in the bathroom, then emptied the bathroom trash can. Without changing gloves, she proceeded to clean the resident's room, sink, and mirror before returning to clean the bathroom.
Professional infection control standards require moving from cleaner to dirtier areas to prevent spreading microorganisms. Bathrooms are considered among the most contaminated areas in healthcare settings and should be cleaned after other room surfaces. The housekeeper also failed to clean call light cords in either the room or bathroom.
When interviewed, housekeepers indicated they had received minimal orientation and had not received recent education or training. One housekeeper said she believed she did not need to change gloves between cleaning tasks. Another stated that call lights were only cleaned on "deep clean days" occurring once or twice weekly, rather than daily.
The facility's water management plan had not been updated since 2021, and the administrator could not provide documentation that the facility had tested for Legionella bacteria after 2021, despite the plan stating such testing would occur. Legionella can cause serious pneumonia, and water management programs are industry standard for healthcare facilities.
Missing Medical Records
The facility destroyed Medical Orders for Scope of Treatment (MOST) forms for discharged and deceased residents approximately one month before the inspection, according to the administrator. This included the MOST forms for a resident who passed away, including documentation of a critical code status change from full resuscitation to do-not-resuscitate made on the day of death.
The nurse practitioner and regional clinical consultant confirmed that MOST forms are considered physician's orders and part of the permanent medical record that should never be destroyed. The regional consultant conducted facility-wide training during the survey to ensure staff understood that no part of residents' medical records should be destroyed.
Facility Response and Ongoing Concerns
Durango Health and Rehabilitation's deficiencies reflect systemic issues in medication management, dietary services, infection control, and record-keeping. The medication errors involving insulin substitution and delayed thyroid medication administration demonstrate gaps in nursing protocols and communication with prescribing physicians.
The prolonged dietary error affecting the Parkinson's patient reveals breakdowns in coordination between nursing and dietary departments, as well as insufficient verification systems to ensure meal tickets match physician orders.
Federal regulations require nursing homes to be free from medication errors and to provide food prepared in forms designed to meet individual resident needs. These standards exist to protect vulnerable residents who depend on accurate medication administration and appropriate nutrition for their health conditions.
The facility received citations for minimal harm or potential for actual harm, indicating inspectors determined the violations had limited negative impact on residents. However, the patterns documented suggest broader quality assurance concerns requiring systematic corrections.
For complete inspection details, the full federal survey report is available through Medicare's Nursing Home Compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Durango Health and Rehabilitation from 2024-06-27 including all violations, facility responses, and corrective action plans.
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