Durango Health And Rehabilitation

F-F760 for failure to ensure residents were free of significant medication errors.

On 6/26/24 at 8:59 a.m. registered nurse (RN) #1 was observed preparing and administering medications to Resident #26, who was lactose intolerant (a condition that prevents the body from digesting lactose, a sugar found in dairy products).

The physician's order was for Lactaid 3000 units one tablet by mouth.

RN #1 was unable to find the medication in her medication cart. She proceeded to administer Resident #26's other medications mixed in yogurt, which contained dairy.

RN #1 gave Resident #26 the remainder of the container of yogurt to eat with his breakfast. She said she would go look for the correct dose of Lactaid in the other medication storage areas.

On 6/26/24 at 9:05 a.m. ADON #1 was observed preparing and administering medication to Resident #29.

The physician's order was for levothyroxine 275 micrograms (mcg) by mouth in the morning.

-The medication was scheduled to be administered at 7:30 a.m., however, ADON #1 administered the medication at 9:05 a.m., which was 90 minutes after it was scheduled and after the resident had already eaten breakfast.

V. Additional interviews

ADON #2 was interviewed on 6/25/24 at 6:48 p.m. regarding the insulin she had administered to Resident #67. She reviewed the physician's order that was for the insulin lispro pen. ADON #2 said the resident's insurance would not cover the insulin pens so the facility had to use the Humulin R insulin from the vial. She said the physician should have been notified to change the order and she said she would take care of it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 RN #1 was interviewed on 6/26/24 at 10:34 a.m. She said she had not found the correct dose of Lactaid (the facility only had the 9000 unit dose available) but had one more place to look. She said she felt bad for giving Level of Harm - Minimal harm or Resident #26 the yogurt without his Lactaid. potential for actual harm

On 6/26/24 at 10:45 a.m,.RN #1 said she contacted Resident #26's physician and got his Lactaid order Residents Affected - Some changed to 9000 units. She said she was able to administer the new dose of Lactaid to Resident #26.

-However, Resident #26 did not receive the medication timely or per the manufacturer's guidelines (see above).

The director of nursing (DON) was interviewed on 6/27/24 at 6:45 pm. The DON said the wrong insulin was administered to Resident #67.

The DON said the Lactaid order should have been changed and it had not been administered to Resident #26 at the correct time . She said Resident #26 should not have been given a dairy product when his Lactaid had not been administered.

The DON said Resident #29's levothyroxine was administered after breakfast was not given timely.

The consulting pharmacist (CP) was interviewed on 6/27/24 at 1:59 p.m. The CP said taking levothyroxine could be affected by specific foods if taken after eating them. He said it was recommended to take the medication on an empty stomach.

The CP said the insulin lispro and Humulin R (humalog) were two different insulins. He said the insulin lispro was a rapid acting insulin (was effective in about 15 minutes) and Humulin R was short-acting insulin (was effective in about 30 minutes and lasted longer). He said giving Resident #67 Humulin R insulin instead of

the insulin lispro was a medication error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50853 potential for actual harm Based on observation, record review and interviews, the facility failed to ensure one (#67) of nine residents Residents Affected - Few out of 45 sample residents were free from significant medication errors.

Specifically, the facility failed to ensure Resident #67 was administered the correct insulin.

Findings include:

I. Professional reference

According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 7/9/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment.

Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights:

1. The right medication

2. The right dose

3. The right patient

4. The right route

5. The right time

6. The right documentation

7. The right indication.

The American Diabetes Association Insulin Basics,was retrieved on 7/2/24 from https://diabetes. org/health-wellness/medication/insulin-basics. It read in pertinent part,

Rapid-acting insulin, begins to work about 15 minutes after injection, peaks in about one or two hours after injection, and lasts between two to four hours. Types: insulin aspart (Fiasp, NovoLog) Insulin glulisine (Apidra), and insulin lispro (Admelog, Humalog, Lyumjev).

Regular or short-acting insulin usually reaches the bloodstream within 30 minutes after injection, peaks anywhere from two to three hours after injection, and is effective for approximately three to six hours. Types: Human Regular (Humulin R, Novolin R, Velosulin R).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 II. Facility policy and procedure

Level of Harm - Minimal harm or The Diabetic Management policy, dated 3/19/24, was provided by the nursing home administrator (NHA) on potential for actual harm 6/27/24 at 7:29 p.m. It read in pertinent part,

Residents Affected - Few Upon admission the interdisciplinary team (IDT) evaluates the diabetic resident and implements a plan of care to ensure orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents, antidiabetic agents (insulin or oral) are administered per physician's order and insulin is labeled properly with a pharmacy label.

III. Manufacturer's Guidelines

According to the manufacturer's guidelines for insulin lispro (Humalog), retrieved on 7/9/24 from https://www. accessdata.fda.gov/drugsatfda_docs/label/2017/020563s172,205747s008lbl.pdf, Humalog is a rapid acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus. Administer Humalog by subcutaneous (under the skin) injection within 15 minutes before a meal or immediately after a meal.

According to the manufacturer's guidelines for Humulin R insulin, retrieved on 7/9/24 from https://pi.lilly. com/us/humulin-r-pi.pdf, Humulin R is a short acting human insulin indicated to improve glycemic control in adults with diabetes mellitus. Inject subcutaneously 30 minutes before a meal.

IV. Observation

On 6/25/24 at 4:41 p.m. assistant director of nursing (ADON) #2 was observed preparing and administering medications to Resident #67.

The physician's order was for insulin lispro (Humalog) 100 units/milliliter (ml) pen, inject as per sliding scale.

If blood sugar is:

0 - 199 = 0 units;

200 - 249 = 1 unit;

250 - 299 = 2 units;

300 - 349 = 3 units;

350 - 399 = 4 units;

400 - 449 = 5 units;

450 - 499 = 6 units;

500 - 600 = 8 units,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 subcutaneously every 4 (four) hours for diabetes mellitus. Notify the physician for blood sugar less than 60 milligrams/deciliter (mg/dl) after carbohydrate supplement or greater than 400. mg/dl. The order date of the Level of Harm - Minimal harm or medication was 2/2/24. potential for actual harm ADON #2 obtained a blood sugar reading of high on the glucometer. ADON #2 said that meant the resident's Residents Affected - Few blood sugar was over 600 mg/dl and she would need to give eight units of insulin.

ADON #2 took a vial of insulin from the resident's insulin storage box. The insulin vial read Humulin R and there was not a pharmacy label on the vial. She drew up eight units in an insulin syringe and administered it to Resident #67.

-ADON #2 administered the incorrect insulin to Resident #67.

C. Interviews

ADON #2 was interviewed on 6/25/24 at 6:48 p.m. regarding the insulin she had administered to Resident #67. She reviewed the physician's order that was for the insulin lispro pen. ADON #2 said the resident's insurance would not cover the insulin pens so the facility had to use the Humulin R insulin from the vial. She said the physician should have been notified to change the order and she said she would take care of it.

The director of nursing (DON) was interviewed on 6/27/24 at 6:45 pm. The DON said the wrong insulin was administered to Resident #67.

The consulting pharmacist (CP) was interviewed on 6/27/24 at 1:59 p.m. The CP said the insulin lispro and Humulin R (humalog) were two different insulins. He said the insulin lispro was a rapid acting insulin (was effective in about 15 minutes) and Humulin R was short-acting insulin (was effective in about 30 minutes and lasted longer). He said giving Resident #67 Humulin R insulin instead of the insulin lispro was a medication error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 50853 Residents Affected - Few Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of six medication carts and one of two medication storage rooms.

Specifically, the facility failed to:

-Ensure medications were properly labeled with open dates; and,

-Ensure expired medications were removed from the medication cart and storage rooms.

Findings include:

I. Professional reference

The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, retrieved on 7/2/24 from https://www.fda. gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.

II. Observations

On 6/27/24 at 2:20 p.m. the medication cart on the Junction hallway was observed with licensed practical nurse (LPN) #1. The following items were found:

-An open Tresiba FlexTouch Pen-injector was not labeled with the date opened; and,

-An open bottle of isopropyl alcohol had an expiration date of May 2024.

On 6/27/24 at 3:30 p.m. the medication storage room on the Sunflower hallway was observed with LPN #3.

The following items were found:

-One bottle of multivitamin with minerals that expired in October 2023;

-One bottle of esomeprazole magnesium that expired in February 2024;

-One bottle of vitamin B12 100 micrograms (mcg) that expired in October 2023;

-One bottle of loperamide HCL 2 milligrams (mg) expired in January 2024;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 -One bottle of spironolactone 50 mg that expired on 2/21/24;

Level of Harm - Minimal harm or -One bottle of omeprazole 20 mg that expired on 4/19/24; and, potential for actual harm -One bottle of furosemide 20 mg that expired on 2/21/24. Residents Affected - Few

On 6/27/24 at 4:30 p.m. the medication cart on the Primrose hallway was observed with assistant director of nursing (ADON) #2. The following item was found:

-One package of omeprazole that expired in May 2024.

III. Staff interviews

LPN #1 was interviewed on 6/27/24 at 2:20 p.m. LPN #1 said the insulin pens should be dated when they were opened. He said he would dispose of the expired isopropyl alcohol.

Registered nurse (RN) #2 was interviewed on 6/27/24 at 3:40 p.m. RN #2 said expired medications should be disposed of. She said she would put the expired medications in the drug buster (a container utilized for destroying medications).

ADON #2 was interviewed on 6/27/24 at 4:30 p.m. She said the expired package of omeprazole should have been removed from the medication cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 47818

Residents Affected - Many Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs.

Specifically, the facility failed to ensure food items served were consistent with the posted daily menu.

Findings include:

I. Facility policy and procedure

The Menus policy, revised October 2022, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:30 p.m. It read in pertinent part,

Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide.

Procedures: Menu cycles will include standardized recipes,menus will be served as written, unless a substitution is provided in a response to preference, unavailability of an item or a special meal. Menu substitution log will be maintained on file.

II. Resident interviews

Resident #58 and Resident #40 were interviewed together on 6/24/24 at 3:04 p.m. Resident #58 said the facility menus offered a decent selection but the food items did not always match the posted menus. Resident #58 said the menu items were not always available and if they were out of something, the kitchen would just put something else on the plate without informing the residents or asking if it was okay to substitute a listed food item.

Resident #40 agreed with the information provided by Resident #58.

III. Meal observations and resident interviews

The 6/24/24 dinner menu revealed residents were to be served shrimp scampi, spaghetti noodles, sauteed asparagus cuts, Italian herbed dinner roll and chilled peach parfait. Alternative options were cheese pizza and sauteed green beans.

During a continuous observation on 6/24/24, beginning at 5:30 p.m. and ending at 7:00 p.m., the dinner being served was plain spaghetti noodles topped with a thick white sauce with cooked shrimp on top of the sauce and snow peas.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 -The sauteed asparagus or sauteed green beans were not available as the menu indicated, and the shrimp scampi had the addition of the cream, which was not indicated as an ingredient on the recipe (see below). Level of Harm - Minimal harm or potential for actual harm The 6/25/24 lunch menu revealed residents were to be served homestyle meatloaf with ketchup topping, duchess mashed potatoes, broccoli florets, poppy seed dinner roll and cherry cheesecake for dessert. Residents Affected - Many

During a continuous observation on 6/25/24, beginning at 12:00 p.m. and ending at 12:45 p.m., the lunch being served did not include broccoli florets and had green beans instead.

Resident #37 was interviewed on 6/25/24 at 1:00 p.m. Resident #37 said he did not ask for green beans instead of broccoli florets for lunch.

Resident #64 was interviewed on 6/25/24 at 1:10 p.m. Resident #64 said he did not ask for green beans instead of broccoli florets for lunch.

Resident #27 was interviewed on 6/25/24 at 1:15 p.m. Resident #27 said she informed the staff member taking her lunch order earlier that she did not want the meatloaf or mashed potatoes but had received it anyway. Resident #27 said she told staff she would make herself a tuna fish sandwich from the personal food items. Resident #27 said she had asked for tuna fish sandwiches from the facility kitchen in the past and was told it was not currently available as a menu item.

IV. Shrimp scampi recipe

The facility's shrimp scampi recipe was provided by the dietary manager (DM) on 6/27/24 at 4:15 p.m. The recipe revealed the following ingredients:

-Hot water;

-Chicken soup base;

-White wine;

-Vegetable oil;

-Oregano and black pepper;

-Garlic (minced and chopped);

-Peeled and deveined shrimp; and,

-Fresh lemon.

-The shrimp scampi recipe did not indicate to use heavy cream.

V. Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 The DM and the dietary consultant (DC) were interviewed on 6/27/24 at 4:14 p.m. The DM said she followed

the recipe for shrimp scampi and added cream which was not listed on the recipe. The DM said she was Level of Harm - Minimal harm or instructed by the previous kitchen manager to do so. The DM said the residents and the staff were not potential for actual harm informed there was the addition of cream to the shrimp scampi recipe. The DM said she did not consider complications for the residents who did not prefer or could not have dairy products. Residents Affected - Many

The DM and the DC said they were responsible for authorizing menu changes.

The DM said the kitchen had started making more soups from scratch which was using more of the ingredients. The DM said the cooks needed to communicate better to ensure there were enough vegetables and other ingredients.

The DC said a poll was recently conducted with the residents regarding what food items should be included

on the always available menu. The DM said the poll revealed tuna fish sandwiches were included in the poll but did not get enough votes to be an always available item. The DM said she would speak with Resident #27 regarding her food preference with having tuna fish sandwiches for lunch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47818 potential for actual harm Based on interviews and observations, the facility failed to consistently serve food that was palatable, Residents Affected - Some attractive and at a safe and appetizing temperature.

Specifically, the facility failed to ensure resident food was served at palatable temperatures.

Findings include:

I. Facility policy and procedure

The Food: Quality and Palatability policy, revised February 2023, was received by the nursing home administrator (NHA) on 6/27/24 at 7:30 p.m. It read in pertinent part,

Food will be prepared by methods that can serve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature.

Proper (safe and appetizing) temperature: food should be at the appropriate temperature as determined by

the type of food to ensure residents satisfaction and minimize the risk for scalding and burns.

II. Resident group interview

Six alert and oriented Resident's (#27, #37, #63, #32, #64 and #15), who were identified as alert and oriented per the facility and assessment, were interviewed in a group meeting on 6/26/24 at 10:00 a.m.

Resident #27 and Resident #37 said the food was cold regardless of eating in either the dining room or being served a room tray. The remaining residents (#63, #32, #64 and #15) all agreed with this information.

III. Observation

On 4/25/24 at 7:20 p.m. a test tray for a regular diet, which was served immediately after the last resident had been served their room tray, was evaluated by the dietary manager (DM) for serving temperatures.

The test tray was plated in the kitchen at 6:10 p.m. and the last tray on the unit was delivered at 7:20 p.m.

The test tray meal consisted of shrimp scampi, spaghetti noodles and snow peas for dinner and peach parfait for dessert.

Temperatures of the test tray were taken at the delivery cart and were as follows:

-The spaghetti noodles were 123 degrees fahrenheit (F).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 -The snow peas were 109 degrees F.

Level of Harm - Minimal harm or -The shrimp scampi was 112 degrees F. potential for actual harm -The temperatures were all below the palatable temperature of 135 degrees F for hot foods. Residents Affected - Some IV. Staff interview

The DM was interviewed on 4/25/24 at 7:20 p.m. The DM said the food carts used for passing room trays were not heated and a plate warmer was used in the kitchen to keep food at a palatable temperature throughout meals services. The DM said a palatable food temperature was at or above 135 degrees F. The DM said the heated plates were not successful with keeping food at the desired temperature.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50690

Residents Affected - Few Based on observations, interviews and record review, the facility failed to ensure one (#50) out of one resident reviewed for mechanically altered diets out of 45 sample residents received food prepared in a form designed to meet her needs.

Specifically, the facility failed to provide Resident #50 the correct mechanically-altered diet as prescribed.

Findings include:

I. Facility policy and procedure

The Diet and Nutrition Care Manual- Chapter two: Consistency alterations, revised in 2019, was provided by

the dietary consultant (DC) on 6/27/24 at 12:02 p.m. It read in pertinent part,

Dysphagia advanced diets: Vegetables included cooked, tender, chopped, shredded; protein foods included chopped or ground as tolerated.

To achieve optimal intake, diets should be planned with the individual's preferences in mind.

II. Resident # 50

A. Resident status

Resident #50, age 79, was admitted on [DATE REDACTED]. According to the June 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement), malnutrition and gastroesophageal reflux disease (GERD).

The 3/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 15 out of 15. She required set up and clean up assistance for eating.

The assessment indicated the resident had no weight change in the last six months. Resident #50 had no signs of a possible swallowing disorder and was prescribed a mechanically-altered diet.

B. Observations

On 6/24/24 at 10:59 a.m. Resident #50 was sitting in bed. There was pureed food on her breakfast plate.

-However, according to the dysphagia advanced diet, she should not have received pureed foods.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 On 6/25/24 at 6:33 p.m. Resident #50's dinner meal was observed. It consisted of whole spaghetti noodles with small pieces of shrimp, a pureed green vegetable, a pureed dinner roll, a pureed orange dessert and Level of Harm - Minimal harm or tea. potential for actual harm -The resident was served pureed food items instead of dysphagia advanced (see interviews below). Residents Affected - Few

On 6/27/24 at 12:54 p.m. Resident #50 finished lunch in her room. Her meal ticket indicated she was prescribed a dysphagia mechanical soft diet.

-The resident's meal ticket did not indicate the correct diet of dysphagia advanced (see interviews below).

C. Resident interview

Resident #50 was interviewed on 6/24/24 at 3:53 p.m. Resident #50 said she had Parkinson's disease. She said the facility mashed all of her food. She said the flavor was not good and had no taste.

Resident #50 was interviewed again on 6/24/24 at 5:07 p.m. Resident #50 said the facility ground and mashed all of her food. She said she had no history of choking and did know that she was on a special diet.

D. Record review

The June 2024 CPO revealed the following diet order: Regular diet, dysphagia advanced texture, regular/thin consistency (resident does not like dairy products), ordered on 12/6/23 and revised on 4/27/24.

The 2/13/24 speech therapy discharge summary documented Resident #50's dysphagia outcome and severity score (DOSS) was six out of seven. This indicated mild dysphagia and a recommended diet of soft and bite-sized foods: soft, tender and moist, but with no thin liquid leaking or dripping from the food. The ability to bite off a piece of food was not required. The ability to chew bite-sized pieces so that they were safe to swallow was required. Bite-sized referred to pieces no bigger than 1.5 centimeter (cm) by 1.5 cm in size. Food could be mashed or broken down with pressure from a fork. A knife was not required to cut the food according to the international dysphagia diet standardization initiative (IDDSI).

E. Menu extension

The menu extensions were provided by the dietary manager (DM) on 6/24/24 at 9:13 a.m. They revealed the following:

The menu extensions indicated residents who were prescribed a dysphagia advanced diet were to receive whole bananas foster french toast and a ground sausage patty with brown gravy for breakfast on 6/24/24.

-However, Resident #50 received pureed french toast and pureed sausage for breakfast on 6/24/24 (see

observation above).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 III. Staff interviews

Level of Harm - Minimal harm or Certified nurse aide (CNA) #1 was interviewed on 6/26/24 at 3:42 p.m. CNA #1 said Resident #50 never had potential for actual harm choking issues. CNA #1 said when Resident #50 admitted to the facility staff had supervised her while she ate. She said the resident was fine eating on her own and did not like assistance. Residents Affected - Few

The speech language pathologist (SLP) was interviewed on 6/27/24 at 9:06 a.m. The SLP said she had evaluated and treated Resident #50 for dysphagia and voice concerns in the past. She said the resident had Parkinson's disease. The SLP said sometimes residents with Parkinson's disease had or developed oral issues and swallowing difficulty. The SLP said she saw Resident #50 when she first admitted to the facility and worked with her on swallowing and chewing.

The SLP said after evaluating and working with Resident #50, she recommended the resident to be on a dysphagia advanced diet. She said that was the diet level below a regular diet and consisted of naturally soft and bite-sized foods. The SLP said when she discontinued working with Resident #50 on 2/12/24, her food did not need to be pureed.

The SLP said the diet that was on Resident #50's meal ticket needed to match the physician's order. She said she did not know how or why Resident #50's diet was changed.

The SLP said when she was working with the resident, she was served the correct diet at meals. She said examples of food on a dysphagia advanced diet included soft vegetables usually cut-up, meat that was relatively/naturally soft and easy to chew and mashed potatoes. The SLP said the dysphagia mechanical soft diet was mushy soft foods. She said the kitchen made a lot of pureed sides and did not follow the IDDSI framework.

Assistant director of nursing (ADON) #1 was interviewed on 6/27/24 at 10:04 a.m. ADON #1 said Resident #50's physician prescribed diet order was a dysphagia advanced diet. ADON #1 said if a diet change was made, nursing staff were notified first. She said the licensed nurses put in the new order, filled-out a diet sheet and gave it to the dietary department to notify them of the diet change.

The director of nursing (DON) was interviewed on 6/27/24 at 10:31 a.m. The DON said Resident #50 was prescribed a dysphagia advanced diet. She said the procedure for diet changes involved the facility nurses entering the new order then giving the diet change order to the dietary manager. She said the expectation was for staff to check the meal ticket to ensure it matched the physician's order. She said if there was a discrepancy, then they talked to the kitchen to see if it was the wrong tray or the wrong physician's order.

She said if the meal ticket for the resident's order was wrong, the nurses wrote a diet order change and provided it to the kitchen for clarification.

The DON said usually what was in the computer was the most updated order. She said the dietary department did not get that information until the nurses did. She said she did not know how the dietary department got information that the resident was on a different type of diet. She said there should be a comparison made between the diets and physician's orders on a regular basis, where she provided a list of all the diet orders to the dietary department, and then the dietary staff ensured the meal tickets were accurate. She said the diet order for Resident #50 should have been clarified and updated on the meal ticket to ensure the resident received the correct mechanically altered diet

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 The DC was interviewed on 6/27/24 at 12:02 p.m. The DC said the meal ticket system indicated Resident #50's diet changed on 5/5/24. The DC said the meal ticket system was not an actual physician's order. She Level of Harm - Minimal harm or said a requisition was needed to make dietary changes and they did not serve residents' food without a potential for actual harm correct order. She said the dietary department rarely used mechanical soft diets and if she saw that on an order she would have questioned it. She was unaware of how Resident #50's change in diet showed up on Residents Affected - Few her dietary profile without going through the proper steps.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38185

Residents Affected - Few Based on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for one (#78) of one resident out of 45 sample residents.

Specifically, the facility failed to ensure Medical Orders for Scope of Treatment (MOST) forms were not destroyed when residents were discharged from the facility.

Findings include:

I. Facility policy and procedure

The Advanced Directives policy and procedure, dated [DATE REDACTED], was provided by the nursing home administrator (NHA) on [DATE REDACTED] at 4:24 p.m. It revealed in pertinent part, The resident or legal responsible party will be provided with written information that explains their rights under law to give informed consent and to either refuse or accept health care and treatment.

All advanced directives forms shall be kept in a binder at the nurses station.

II. Resident #78

A. Resident status

Resident #78, age 80, was admitted on [DATE REDACTED] and passed away on [DATE REDACTED]. According to the [DATE REDACTED] computerized physician orders (CPO), diagnoses included atherosclerotic heart disease and chronic obstructive pulmonary disorder (COPD).

The February 2024 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15.

B. Record review

The [DATE REDACTED] CPO documented the following physician's order:

COR status (whether or not a person wants cardiopulmonary resuscitation): CPR (cardiopulmonary resuscitation), Full Code (indicates all measures, including CPR to be taken to resuscitate a person), ordered [DATE REDACTED] and discontinued on [DATE REDACTED].

The [DATE REDACTED] CPO documented the following physician's order:

ADC (advanced directive care): Do not resuscitate (DNR), ordered on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The [DATE REDACTED] nursing progress note documented Resident #78t had been declining over the past month and

he had started refusing to eat and began drinking a very little amount. The resident began having air hunger Level of Harm - Minimal harm or (a feeling of needing to breathe more air), coughing and vomiting mucus. The resident did not want to be potential for actual harm sent to the hospital and decided he wanted to change his code status to a DNR.

Residents Affected - Few The progress note further documented Resident #78 amended his MOST form to change his full code status to a DNR. It was witnessed by two nurses.

-A review of the resident's electronic medical record (EMR) on [DATE REDACTED] at 2:00 p.m. did not reveal documentation of the initial MOST form documenting Resident #78's wishes to be a full code, nor the amended MOST form on

[DATE REDACTED] indicating the resident wished to change his status to a DNR.

III. Staff interviews

The NHA was interviewed on [DATE REDACTED] at 2:25 p.m. The NHA said the facility considered the MOST form a portable document that was given to families upon discharge or shredded in the case of death. He said the facility destroyed all MOST forms from discharged or expired residents approximately one month ago ([DATE REDACTED]). He said he did not feel the MOST form was part of the resident's medical record.

The NHA said the facility did not have record of either of Resident #78's MOST forms.

Registered nurse (RN) #2 and the infection preventionist (IP) were interviewed on [DATE REDACTED] at 3:28 p.m. RN #2 said Resident #78 had been declining prior to his death on [DATE REDACTED]. She said, on [DATE REDACTED], the resident had been having difficulty breathing and was refusing to eat and drink. RN #2 said as his condition was deteriorating that day, she discussed with him the facility's responsibility to send him to the hospital because his MOST indicated that he was a full code.

RN #2 said Resident #78 did not want to go to the hospital and decided to change his MOST form to reflect

he wanted to be a DNR status. She said the IP joined her to witness the resident change his status.

The IP said the facility had destroyed the MOST forms of all residents that had discharged or expired. She said Resident #78's MOST form was part of the destruction. The IP said she was told the MOST form was not part of the resident's medical record. The IP said the MOST form was considered a physician's order.

She said all other physician's orders had been retained in the resident's EMR.

The NHA was interviewed again on [DATE REDACTED] at 4:08 p.m. The NHA said the facility did not have a policy on destroying the MOST form after a resident had been discharged from the facility. He said the MOST form was not kept in the resident's permanent medical record.

The nurse practitioner (NP) was interviewed on [DATE REDACTED] at 4:26 p.m. She said RN #2 called her and spoke with her regarding Resident #78's declining condition on [DATE REDACTED]. She said she made sure, on four occasions that day, that Resident #78 had changed his mind and was happy with his decision. The NP said she gave orders to provide the resident with comfort measures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The NP said the MOST form was considered a physician's order and part of the resident's medical record.

She said the facility should never have destroyed resident MOST forms. She said the facility had destroyed Level of Harm - Minimal harm or part of the resident's medical record. potential for actual harm

The regional clinical consultant (RCC) was interviewed on [DATE REDACTED] at 5:22 p.m. The RCC said she was not Residents Affected - Few aware who gave the direction to the facility to destroy MOST forms of residents that had discharged or expired from the facility.

The RCC said the MOST form was considered part of the resident's permanent medical record and should not have been destroyed. She said she conducted a facility-wide training that day ([DATE REDACTED]) to ensure the facility staff were aware that any part of the resident's medical record should not be destroyed.

The RCC said the MOST form should have been uploaded to Resident #78's EMR when he passed away and not destroyed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50314 potential for actual harm Based on observations, record review and interviews, the facility failed to maintain an infection control Residents Affected - Some program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.

Specifically, the facility failed to:

-Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate;

-Ensure housekeeping staff properly sanitized resident rooms;

-Dispose of contaminated medication pass water cups;

-Offer hand hygiene to residents before meals; and,

-Implement an effective water management plan.

Findings include:

I. Housekeeping failures

A. Professional reference

The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 7/9/24 from https://www.cdc. gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It read in pertinent part,

High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility.

Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.

Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones)

before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of

the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 B. Observations

Level of Harm - Minimal harm or On 6/26/24 at 9:32 a.m. housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER]. HSKP #1 potential for actual harm donned (put on) a pair of gloves and began spraying disinfectant in the bathroom. HSKP #1 then emptied the trash can in the bathroom. Residents Affected - Some Without changing gloves, HSKP #1 began to clean the resident room, the sink and the mirror. After cleaning

the resident's room, HSKP #1 changed her cleaning cloth and began cleaning the resident's bathroom. HSKP #1 moved the resident's commode to the opposite side of the bathroom to clean the toilet. When HSKP #1 finished cleaning the resident's bathroom, she removed her gloves for the first time and performed hand hygiene.

-The call light cord in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during

the room cleaning process.

-HSKP #1 failed to sanitize the room properly by moving from clean to dirty surfaces.

-HSKP #1 failed to change her gloves and perform hand hygiene after touching potentially contaminated surfaces and items including the resident's trash can.

-HSKP #1 failed to sanitize the resident's commode.

On 6/11/24 at 9:14 a.m. HSKP #2 was observed cleaning room [ROOM NUMBER].

-HSKP #2 was sanitizing and cleaning the bathroom before she began to clean the resident's room.

-HSKP #2 failed to sanitize the room properly by moving from clean to dirty surfaces.

-The call light cord in the resident's room and resident's bathroom were not cleaned by HSKP #2 during the room cleaning process.

C. Facility documentation

Housekeeping in-service documentation, not dated, was obtained from the corporate consultant (CC) on 6/26/24 at 10:42 a.m. It documented the five step daily patient room cleaning procedure included emptying trash, disinfecting horizontal surfaces, spot clean walls, dust mop the floor, and then damp mop the floor. It documented the seven-step washroom cleaning process included checking supplies, emptying trash, dust mop the floor, clean and sanitize the sink and tub, clean and sanitize the commode, spot clean walls and/or partitions, and damp mop the floor.

-The documentation failed to identify when housekeepers should perform hand hygiene or change gloves.

D. Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 HSKP #1 was interviewed on 6/26/24 at 9:53 a.m. HSKP #1 said she did not need to clean the resident's commode because the resident did not use the commode. HSKP #1 said she cleaned the residents' call Level of Harm - Minimal harm or lights sometimes but not all the time. HSKP #1 said she needed to put gloves on to clean a room, but did not potential for actual harm have to change her gloves between cleaning tasks. HSKP #1 said she was given two days of orientation when she began her housekeeping role. HSKP #1 said she had not received education or training in the last Residents Affected - Some few months.

HSKP #2 was interviewed on 6/27/24 at 9:31 a.m. HSKP #2 said housekeepers did not clean resident call lights every day, but only cleaned them on deep clean days that occurred once or twice a week. HSKP #2 said her orientation was very short upon hire. HSKP #2 said she had not received training or education in the last few months.

The infection preventionist (IP) and the CC were interviewed together on 6/27/24 at 3:23 p.m. The IP said

she had not provided the housekeeping staff with education. The CC said housekeeping staff were contracted outside of the facility. The CC said the facility administration needed to audit the housekeeping company to ensure proper sanitation practices were upheld.

II. Failure to offer hand hygiene to residents before meals

A. Facility policy and procedure

The Hand Hygiene policy, undated, was obtained from the nursing home administrator (NHA) on 6/25/24 at 4:12 p.m. It documented in pertinent part, Hand hygiene will be performed before and after eating.

B. Observations

During a continuous observation on 6/24/24, beginning at 11:31 a.m. and ending at 12:28 p.m., the following was observed in the main dining room:

-At 11:48 a.m. Resident #33 was observed self-propelling himself in a wheelchair to a table. He was not offered hand hygiene before or after his meal.

-At 11:58 a.m. Resident #16 was observed self-propelling himself in a wheelchair to a table. He was not offered hand hygiene before or after his meal.

-At 12:11 p.m. an unidentified resident wearing a green shirt and red sweatpants, was observed self-propelling himself in a wheelchair. The resident was not offered hand hygiene before or after his meal.

The resident was observed eating a sandwich with his hands.

During a continuous observation on 6/25/24, beginning at 5:22 p.m. and ending at 6:36 p.m., the following was observed in the main dining room:

-At 5:46 p.m. the NHA was offering residents drinks. She did not offer the residents hand hygiene.

-At 5:57 p.m. Resident #16 self-propelled himself in a wheelchair to a dining room table. He was not offered hand hygiene before or after his meal. He used his hands to eat two breaded chicken breasts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -At 6:04 p.m. Resident #33 self-propelled himself in a wheelchair to a dining table. He was not offered hand hygiene before or after his meal. He used his hands to eat a sandwich. Level of Harm - Minimal harm or potential for actual harm B. Resident interview

Residents Affected - Some Resident #16, who was cognitively intact, was interviewed on 6/24/24 at 10:17 a.m. Resident #16 said the facility did not offer hand hygiene before or after meals in the main dining hall.

C. Staff interviews

The IP was interviewed on 6/27/24 at 3:23 p.m. The IP said hand hygiene was one of the key components of infection prevention. The IP said residents should be offered hand hygiene before and after every meal.

III. Failure to dispose of contaminated medication pass water cups

A. Observations

On 6/26/24 at 3:30 p.m. registered nurse (RN) # 2 was observed by the medication cart. Several medication cups fell off of the cart onto the floor. RN #2 picked up the cups and placed them on top of the medication cart.

B. Staff interviews

RN #2 was interviewed on 6/26/24 at 3:45 p.m. RN #2 said she should have thrown the cups away that had been on the floor. RN #2 said she would not use the cups and would instead throw them away.

-RN #2 disposed of the cups, but did not sanitize the medication cart where the contaminated cups had been placed.

The DON was interviewed on 6/27/24 at 3:23 p.m. The DON said the nurses should dispose of medication cups if they fell on the floor.

IV. Failure to have an effective water plan

A. Professional reference

According to The CDC's Legionella (Legionnaires Disease and Pontiac fever), (3/25/21), retrieved on 7/10/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview. html,

Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of Level of Harm - Minimal harm or pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher potential for actual harm risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Residents Affected - Some Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever.

The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella.

Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review.

Seven key elements of a Legionella water management program are to:

-Establish a water management program team

-Describe the building water systems using text and flow diagrams

-Identify areas where Legionella could grow and spread

-Decide where control measures should be applied and how to monitor them

-Establish ways to intervene when control limits are not met

-Make sure the program is running as designed (verification) and is effective (validation)

-Document and communicate all the activities.

Principles: In general, the principles of effective water management include:

-Maintaining water temperatures outside the ideal range for Legionella growth

- Preventing water stagnation

-Ensuring adequate disinfection

-Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella.

Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. Level of Harm - Minimal harm or potential for actual harm According to the CDC's Controlling Legionella in Potable Water Systems, (2/3/21), retrieved on 7/10/24 from https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-Potable-Water.pdf, Residents Affected - Some Store hot water at temperatures above 140 degrees fahrenheit (F) and ensure hot water in circulation does not fall below 120 degrees F. Recirculate hot water continuously, if possible.

Store and circulate cold water at temperatures below the favorable range for Legionella (77 degrees F to 113 degrees F). Legionella may grow at temperatures as low as 68 degrees F.

B. Record review

The facility's water management plan was obtained from the NHA on 6/27/24 at 3:28 p.m. It documented the water management plan was initiated on 6/27/24. The document was signed by the NHA and the DON

The facility's water management plan, dated 2021, was obtained from the NHA on 6/27/24 at 3:49 p.m. It documented the facility tested for Legionella to ensure the water management plan worked effectively.

However, the facility failed to test the water for Legionella as stated in the water management plan. (see

interview below)

-Additionally, the facility's water management plan was not updated annually.

C. Staff interviews

The NHA was interviewed on 6/27/24 at 3:49 p.m. The NHA said the facility initiated a new water management plan on 6/27/24 (during the survey). The NHA said the facility previously had an effective water management plan. He said the water management plan had not been updated since 2021 and he implemented a new program on 6/27/24 (during the survey). The NHA said he would need to find the testing information for legionella.

-The NHA was interviewed again on 6/27/24 at 4:38 p.m. The NHA said he did not have documentation that

the facility had been testing for Legionella after 2021.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 85 065243 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065243 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Durango Health and Rehabilitation 2911 Junction St Durango, CO 81301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 38185

Residents Affected - Some Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of training per year.

Specifically, the facility failed to:

-Ensure a system was in place to track CNA training to ensure they met the requirements; and,

-Ensure CNA #9 and CNA #10 received the required 12 hours of training per year.

Findings include:

I. Record review

A review of the CNA training records was completed on 6/27/24 at 2:00 p.m.

-CNA #9's training records documented CNA #9 received seven hours of training in the previous calendar year.

-CNA #10's training records documented CNA #10 received eight hours of training in the previous calendar year.

II. Staff interviews

The staff development coordinator (SDC) was interviewed on 6/27/24 at 4:04 p.m. The SDC said she did not have

a system in place to monitor the CNAs yearly training. She said the CNAs were required to receive 12 hours of training per year.

She said CNA #9 received seven hours of training in the calendar year and CNA #10 received eight hours of training in the calendar year, which did not meet the 12 hours of annual training requirement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 85 065243