Rio Grande Rehab: Immediate Jeopardy, Catheter Care - CO
Rio Grande Rehabilitation and Healthcare Center's director of nursing told federal inspectors the facility provided no wound care to Resident #2 during her entire admission from October 22 through November 1, 2025. The reason: nursing staff failed to initiate the physician's wound care orders.
The wound care nurse said she forgot to reassess the wounds and write a baseline care plan for Resident #2's wound care. When asked why the admitting nurse didn't enter the physician's orders, she said she was unsure.
A second resident also experienced problems with wound assessment and care. Resident #1 had a history of a blister on his buttocks that was documented as healed on October 2. But the director of nursing couldn't find any skin assessments for him from October 2 through October 24.
The October 2 skin assessment showed Resident #1 had intact skin. He didn't complain about hemorrhoid pain until November 1, just before he was transferred to the emergency department. The nurse assigned to care for him that day failed to assess his skin for hemorrhoid pain before his hospital transfer due to his changing condition.
The nursing home administrator acknowledged the facility identified a "system failure" on November 3 during the federal inspection. She said wound care orders were missed by nursing staff and that she was working with the director of nursing to develop a process and checklist to ensure nurses reviewed and entered physician's orders into the electronic medical record.
The administrator said facility policy required nurses to complete skin checks every seven to 10 days on every resident. She admitted the October 2025 skin assessments weren't completed for Resident #1 and said she was developing an audit and checklist to ensure skin assessments and documentation were completed according to physician's orders and facility policy.
The wound care nurse explained her usual process: after completing wound evaluations, if there was a need to change wound care orders, she contacted the physician for new orders. But in Resident #2's case, she never completed the initial evaluation that would have triggered the care plan.
Federal inspectors found the facility's failures caused actual harm to a few residents. The missed wound care orders meant Resident #2 went without required treatment during a critical period when wounds can deteriorate rapidly without proper attention.
For Resident #1, the lack of regular skin assessments meant staff missed potential changes in his condition over a three-week period. His hemorrhoid pain only came to light on the day he required emergency hospital transfer.
The director of nursing's inability to locate skin assessment records for nearly a month raised questions about the facility's documentation practices. Federal regulations require nursing homes to conduct comprehensive assessments and develop care plans based on each resident's individual needs.
The wound care nurse's admission that she "forgot" to reassess wounds and write a baseline care plan highlighted gaps in the facility's oversight systems. Wound care requires consistent monitoring and documentation to prevent complications and ensure healing.
The administrator's discovery of the system failure only during the federal inspection suggested the facility lacked adequate internal quality assurance processes. Her promise to develop checklists and audits came after residents had already experienced harm from the missed care.
The nursing home's electronic medical record system was supposed to help staff track and implement physician orders. Instead, the failure to properly enter wound care orders created a gap that left Resident #2 without required treatment for her entire stay.
Both residents' cases revealed a pattern of missed assessments and overlooked orders that the facility only recognized when federal inspectors arrived. The administrator's acknowledgment of system failures and promises of new processes came too late for the residents who had already experienced the consequences of inadequate wound care oversight.
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 20, 2026 · Our methodology
RIO GRANDE REHABILITATION AND HEALTHCARE CENTER in LA JARA, CO was cited for immediate jeopardy violations during a health inspection on November 6, 2025.
The reason: nursing staff failed to initiate the physician's wound care orders.
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.