South Platte Rehabilitation And Nursing Llc
SOUTH PLATTE REHABILITATION AND NURSING LLC in BRUSH, CO — inspection on October 15, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
NP #2, as this was not within her scope of practice.
The DON said LPN #1 should have been communicating with NP #2 and receiving the physician's orders.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
South Platte Rehabilitation and Nursing LLC
2200 Edison St Brush, CO 80723
SUMMARY STATEMENT OF DEFICIENCIES
According to the October 2025 computerized physician orders (CPO), the diagnoses included dementia and bladder neck distention (the bladder is enlarged due to the opening where the bladder connects to the urethra being blocked).The 9/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. He required set-up assistance with eating and partial/moderate assistance with oral hygiene. He was dependent on staff for activities of daily living (ADLs) including dressing, showering, toileting and mobility.
The 9/25/25 MDS assessment revealed the resident used an indwelling catheter.B.
Record reviewResident #3's catheter care plan, initiated on 5/30/24 and revised on 9/5/25, revealed the resident had a suprapubic catheter.
Pertinent interventions included documenting urinary output each shift, monitoring/recording/reporting to the physician any signs or symptoms of urinary tract infection (UTI), ensuring the catheter tubing was securely anchored to prevent accidental removal of the catheter and providing dressing changes to the suprapubic catheter site per the physician's orders.Review of Resident #3's October 2025 CPO revealed a physician's order for the following:Change the suprapubic catheter every month at the facility using an 18-French catheter, every night shift starting on the second and ending on the second of every month, ordered 9/2/25 at 1:36 p.m. and revised on 10/2/25 at 6:00 p.m.Review of Resident #3's electronic medical record (EMR) revealed the suprapubic catheter was last changed by overnight staff on 9/2/25 per physician's order.A nursing progress note, dated 10/3/25, revealed the resident's catheter did not get changed during shift.
The staff reached out to an on-call provider and received authorization to place a one time order for a suprapubic catheter change on the overnight shift for 10/3/25 to 10/4/25.-However, review of Resident #3's EMR did not reveal documentation indicating the resident's catheter had been changed since 9/2/25.III.
Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/13/25 at 1:48 p.m. LPN #1 said an indwelling catheter should be changed every 30 days.
She said she knew that Resident #3's suprapubic catheter had been placed by urology in August
- LPN #1 spent a few minutes searching the resident's EMR to find the date the suprapubic catheter
was last changed.
She said she did not know when the urinary catheter was last changed.The director of nursing (DON) was interviewed on 10/15/25 at 1:12 p.m.
The DON said she was aware Resident #3 had physician's orders for suprapubic catheter care and for the catheter to be changed monthly.
She said the urinary catheter was supposed to be changed on the second, but she saw a note that said the nightshift staff member received a one time order for dayshift to change it.
The DON said based on what she saw documented on the task administration record (TAR), she did not think the catheter change had been completed yet.
She said if the urinary catheter was left indwelling for too long, there could be a chance of infection or the catheter might not work properly.
The DON said the urinary catheter should not be placed and then never replaced or removed.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
South Platte Rehabilitation and Nursing LLC
2200 Edison St Brush, CO 80723
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
with Resident #2 was at 4:45 p.m. on [DATE], when she checked the resident's blood pressure and talked about dinner.
She said during that time, Resident #2 was not cyanotic or gasping at that time. LPN #1 said she guessed it probably would have been her responsibility to switch Resident #2 from the portable canister to the oxygen concentrator. CNA #3 was interviewed on [DATE] at 12:22 p.m. CNA #3 said she was working dayshift on [DATE], but she only went into Resident #2's room for breakfast that morning.
She said Resident #2 did not complain of any pain or shortness of breath at that time and the resident was really good at using her call light to let staff know if she needed something. CNA #3 said it was not routine to regularly round on residents who were on portable oxygen canisters.
She said she did not know who should have been responsible for switching Resident #2 back to her oxygen concentrator when power was restored.The DON was interviewed again on [DATE] at 1:12 p.m.
The DON said someone should have checked on the portable oxygen canister.
She said the portable oxygen canister was full when the SSD put Resident #2 on the portable oxygen tank, but nurses or CNAs should have been monitoring to ensure the canister did not run out of oxygen.
Facility ID: