Rio Grande Rehabilitation And Healthcare Center

F 0600 Level of Harm - Actual harm

monitored the residents closely. She said the staff anticipated the resident's needs and redirected residents when necessary to avoid altercations. The NHA said a staff member was in the same room at the time of

the incident on 9/7/25. The NHA said Resident #11 pushed Resident #10 as they passed each other near

the exit doorway.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Grande Rehabilitation and Healthcare Center

39 Calle Miller LA Jara, CO 81140

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 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

return to complete the wound evaluation and did not verify the wound care orders or initiate a wound care plan of care for Resident #2. The DON said 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 WCN was interviewed on 11/6/25 at 4:45 p.m. The WCN said she was unsure why the admitting nurse did not enter physician's orders for wound care for Resident #1. The WCN said after she completed wound evaluations, if there was a need to change wound care orders, she contacted the physician for new orders. The WCN said she forgot to reassess the wounds and to write a baseline care plan for Resident #2's wound care. The DON was interviewed again on 11/4/25 at 11:00 a.m. The DON said Resident #1 had

a history of a blister on his buttocks that was healed on 10/2/25. The DON said she was unable to find skin assessments for Resident #1 from 10/2/25 to 10/24/25. The DON said the 10/2/25 skin assessment documented Resident #1 had intact skin and had not complained about hemorrhoid pain until 11/1/25, just

before he was transferred to the emergency department. The DON said the nurse assigned to provide care to Resident #1 on 11/1/25 did not assess Resident #1's skin for his hemorrhoid pain prior to his transfer to

the hospital due to the resident's changing condition.The NHA was interviewed on 11/5/25 at 12:25 p.m.

The NHA said she was aware the wound care orders for Resident #2 were not noted or entered by the nursing staff. The NHA said 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 NHA said she was working with the DON to develop a process and a checklist to ensure nurses reviewed and entered physician's orders into

the EMR. The NHA said the policy for skin assessments was that a nurse completed a skin check every seven to 10 days on every resident. The NHA said she was aware the October 2025 skin assessments were not completed for Resident #1. The NHA said she was working with the DON to develop an audit and checklist to ensure skin assessments and documentation were completed according to physician's orders and facility policy.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Grande Rehabilitation and Healthcare Center

39 Calle Miller LA Jara, CO 81140

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 0690 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

obstructed. LPN #1 said when catheters were obstructed, nurses could reposition or flush the catheter with saline in an attempt to have the catheter drain. LPN #1 said that if a catheter occlusion was not cleared, the catheter could be removed and replaced. LPN #1 said if a resident had decreased or no urine output during

the shift, the physician should be notified. The medical director (MD) was interviewed on 11/5/25 at 9:06 a.m. The MD said residents that were quadriplegic could develop autonomic dysreflexia (a potentially life-threatening condition that can occur in people with spinal cord injuries) which could lead to loss of consciousness. He said it was important for nursing staff to assess residents and feel for a full bladder to make sure the Foley catheter drained the bladder properly for those that were quadriplegic because they could not feel pain from a full bladder. The MD said the fact that there was 2000 ml of urine in Resident #2's bladder at the hospital meant the resident's Foley catheter was dysfunctional and should have been assessed and replaced. The MD said nursing care to monitor urine output volume, urine characteristics, and catheter placement were considered standards of practice and should have been completed by the nursing staff.The NHA was interviewed on 11/5/25 at 12:30 p.m. The NHA said she was aware Resident #2 had a change in condition and was transferred to the hospital on [DATE REDACTED]. The NHA said the facility started

an investigation on 11/1/25 regarding Resident #2. The NHA said the investigation was not completed and said they had identified nursing staff would receive inservice education on Foley catheter care and for CNAs to ensure they completed frequent rounding on residents. The NHA said the CNAs should monitor urine output every two hours during their shift. The NHA said the facility had a failure of systems and communication between staff members in regards to Resident #2.

Event ID:

Facility ID:

If continuation sheet