Rio Grande Rehab: Actual Harm Care Failures - CO
The facility's Director of Nursing admitted during a November 6 inspection that staff had provided no wound care to Resident #2 during her entire admission from October 22 to November 1, because they failed to initiate the physician's wound care orders.
"The facility had not provided wound care to Resident #2 during her admission from 10/22/25 to 11/1/25, because they failed to initiate the physician's wound care orders," the Director of Nursing told inspectors.
The wound care nurse, interviewed the same day, said she was "unsure why the admitting nurse did not enter physician's orders for wound care" for another resident. She acknowledged forgetting to reassess wounds and write a baseline care plan for Resident #2's wound care.
A second resident suffered from what administrators called a "system failure" in wound monitoring. Resident #1 had a history of buttocks blisters that were documented as healed on October 2. But the Director of Nursing could not locate any skin assessments for this resident from October 2 through October 24.
The resident's condition deteriorated without proper monitoring. On November 1, Resident #1 complained of hemorrhoid pain for the first time since his October 2 assessment. The assigned nurse failed to assess his skin condition before transferring him to the emergency department due to his changing medical status.
The facility's administrator acknowledged the breakdown during her November 5 interview. She said staff had identified the "system failure" on November 3, during the federal inspection itself, when they discovered the missed wound care orders.
"The facility identified on 11/3/25 (during the survey) that there was a system failure and the wound care orders were missed by the nursing staff," the administrator told inspectors.
The administrator revealed that required skin assessments had not been completed for Resident #1 throughout October 2025, despite facility policy requiring nurses to complete skin checks every seven to 10 days on every resident.
Both cases represented violations of basic wound care protocols. The wound care nurse explained her typical process: after completing wound evaluations, she contacted physicians for new orders when changes were needed. But this system broke down completely for both residents.
For Resident #2, the admitting nurse never entered the physician's wound care orders into the electronic medical record, leaving her without any wound treatment during her 10-day stay. The wound care nurse then compounded the failure by forgetting to reassess the resident's wounds or establish a baseline care plan.
Resident #1's case showed how documentation gaps can mask deteriorating conditions. His October 2 assessment showed intact skin with no complaints of hemorrhoid pain. But with no assessments conducted for three weeks, staff had no warning when his condition changed dramatically on November 1.
The administrator promised corrective measures during her interview. She said she was working with the Director of Nursing to develop a process and checklist ensuring nurses review and enter physician orders into the electronic medical record.
She also pledged to create an audit system and checklist to ensure skin assessments and documentation are completed according to physician orders and facility policy.
The inspection found actual harm to residents from these failures. Federal investigators classified the violation as affecting "few" residents but causing "actual harm" rather than just potential for harm.
The breakdown occurred despite clear facility policies. The administrator confirmed that policy required skin assessments every seven to 10 days for all residents, yet October assessments for Resident #1 were never completed.
The wound care nurse's admission that she "forgot" to reassess wounds and write care plans highlights how individual lapses can compound system failures, leaving vulnerable residents without essential medical care for extended periods.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rio Grande Rehabilitation and Healthcare Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
RIO GRANDE REHABILITATION AND HEALTHCARE CENTER in LA JARA, CO was cited for violations during a health inspection on November 6, 2025.
She acknowledged forgetting to reassess wounds and write a baseline care plan for Resident #2's wound care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.