Rock Canyon Respiratory And Rehabilitation Center

F-F677: The facility failed to provide activities of daily living (ADL) care to dependent residents.

Cross-reference

F-F689: The facility failed to implement effective interventions to prevent falls and bruises.

Cross reference

F-F692: The facility failed to ensure residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. This failure resulted in actual harm with a severe weight loss and a G level citation, actual harm that is not immediate jeopardy, isolated.

Cross-reference

F-F693: The facility failed to administer tube feedings and water flushes accurately and according to physician orders. The facility failed to update physician orders when the tube feeding formula was on backorder and verbally informed staff to use a comparable tube feeding formula. This failure resulted

in substandard care being provided to the residents due to eight out of eight residents having the incorrect formula administered.

Cross-reference

F-F919: The facility failed to install and maintain a working call light system.

IV. Interviews

The nursing home administrator (NHA) was interviewed on 7/12/24 at 5:52 p.m. The NHA said the interdisciplinary team (IDT) met once a month for QAPI. He said the QAPI team used the fishbone diagram (a tool used to identify root causes of a problem) once a specific area was identified as a concern. He said

the facility had a spreadsheet to document each specific concern area identified. The NHA said the QAPI team discussed certain concerns if a grievance was filed about it.

The NHA said tube feedings were not on the QAPI teams' areas of identified concerns within the past 90 days. The NHA said the registered dietician entered the residents' order for tube feedings and the nursing staff followed the orders. The NHA said he was unsure if the clinical staff were not hanging the formula bags correctly, however, he said the facility clearly did not have an effective process to ensure resident tube feedings were being appropriately monitored and managed.

The NHA said falls was a topic covered in every QAPI meeting, which included discussion about interventions and active falls.

The NHA said weight loss was discussed as part of the facility's nutritional program and the QAPI team investigated if the weight loss was desired or not and how to correct the problem. The NHA said he felt the registered dietician consultant needed to provide training to the facility to ensure everyone was on the same page regarding management of weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 48 065100 Department of Health & Human Services Printed: 09/17/2025 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 065100 B. Wing 07/12/2024

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

Rock Canyon Respiratory and Rehabilitation Center 2515 Pitman Pl Pueblo, CO 81004

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 0865 The NHA said the facility would be following up on how to proceed with the concern regarding the lack of an appropriate call light system in the memory care secure unit. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 48 065100 Department of Health & Human Services Printed: 09/17/2025 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 065100 B. Wing 07/12/2024

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

Rock Canyon Respiratory and Rehabilitation Center 2515 Pitman Pl Pueblo, CO 81004

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51163 potential for actual harm Based on observations, record review and interviews the facility failed to adequately equip the residents to Residents Affected - Some call for staff for two (#8 and #24) of three residents out of 29 sample residents and to provide a working call light system in the shower facilities.

Specifically, the facility failed to:

-Provide a working call light for Resident #24 and Resident #8; and,

-Have a functioning call light system in the women's and men's shower areas.

Findings include:

I. Facility policy and procedure

The Call Light/Bell policy and procedure, revised May 2007, was provided by the director of nursing (DON)

on 7/12/24 at 11:54 a.m. It revealed in pertinent part, It is the policy of this facility to provide the residents a means of communication with nursing staff.

II. Resident #24

A. Resident status

Resident #24, age 70, was admitted on [DATE REDACTED]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side (limited or no movement of the resident's dominant side), cerebrovascular disease unspecified, unspecified dementia, abnormal posture, muscle weakness generalized, contracture of left elbow and contracture of muscle left upper arm.

The 6/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He was dependent on staff for oral hygiene, toileting, bathing, dressing upper and lower body, putting on footwear, personal hygiene, transfers and bed mobility. He required supervision or touching assistance with eating.

B. Resident interview and observations

On 7/9/24 at approximately 5:15 p m., Resident #24 was lying in his bed. His room was at the end of the hallway. Resident #24 was yelling for help and did not have a call light.

On 7/10/24 at approximately 12:45 p.m. licensed practical nurse (LPN) #1 and certified nurse aide (CNA) #5 assisted Resident #24 with transferring from his wheelchair to the bed. Resident #24 did not have a call light

in his room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 48 065100 Department of Health & Human Services Printed: 09/17/2025 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 065100 B. Wing 07/12/2024

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

Rock Canyon Respiratory and Rehabilitation Center 2515 Pitman Pl Pueblo, CO 81004

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 0919 On 7/12/24 at approximately 5:00 p.m. the resident had a yellow service bell. The resident had it on his chest. He said he was happy to have a call bell, however, he said when he rang it, the staff did not answer Level of Harm - Minimal harm or him. potential for actual harm C. Record review Residents Affected - Some

The 4/11/24 call system assessment documented #24 was unable to demonstrate using a call bell.

D. Staff interviews

CNA #5 was interviewed on 7/10/24 at approximately 1:15 p.m. CNA #5 said Resident #24 was able to make his needs known. She said none of the residents who resided on the memory care unit had a call light.

CNA #4 was interviewed on 7/11/24 at 9:30 a.m. CNA #4 said Resident #24 was not able to use a call light to make his needs known due to his forgetfulness. He said Resident #24 would be at risk for safety issues such as strangulation due to not understanding what it was for and playing with the long cord.

The social services director (SSD) was interviewed on 7/11/24 at approximately 3:00 p.m. The SSD said she had recently taken over the call bell assessments. She said the assessments consisted of explaining and showing the call bell procedure to the resident. She said she would ask the resident to demonstrate the call bell procedure. She said if the resident could demonstrate the call bell procedure they left the call bell in their room. She said Resident #24 was unable to use the call bell on the last assessment but that she would reassess Resident #24 later that day (7/11/24).

The social service director (SSD) was interviewed again on 7/11/24 at 4:04 p.m. The SSD said the resident was reassessed and it was determined Resident #24 could use a call bell. She said she gave the resident a yellow service bell (see above observations).

III. Resident #8

A. Resident status

Resident #8, age less than 65, was admitted on [DATE REDACTED]. According to the July 2024 CPO, diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, other amnesia (difficulty speaking), muscle weakness, contracture right knee, contracture left knee and rheumatoid arthritis (pain in

the joints).

The 5/8/24 MDS assessment revealed Resident #8 had moderate cognitive impairments with a BIMS score of eight out of 15. The MDS assessment revealed she had limited range of motion in both lower and upper extremities. Resident #8 was dependent on staff for eating, oral hygiene, toileting, showering, dressing lower and upper body, personal hygiene and bed mobility.

B. Observations

On 7/10/24 at 12:20 p.m. Resident #8 was in the dining room, another resident began to eat Resident #8's cake. Resident #8 told the other resident to stop eating her cake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 48 065100 Department of Health & Human Services Printed: 09/17/2025 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 065100 B. Wing 07/12/2024

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

Rock Canyon Respiratory and Rehabilitation Center 2515 Pitman Pl Pueblo, CO 81004

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 0919 On 7/11/24 at 12:00 p.m., the resident was at the medication cart. Registered nurse (RN) #1 was asking her medical questions and she was able to answer appropriately. Level of Harm - Minimal harm or potential for actual harm C. Resident interview

Residents Affected - Some Resident #8 was interviewed on 7/12/24 at 3:00 p.m. Resident #8 said she was glad to have a call bell. She said she was able to use it when she needed to call for staff.

D. Record review

The 5/21/24 call system assessment documented Resident #8 was unable to demonstrate using a call bell.

E. Staff interviews

The SSD was interviewed on 7/11/24 at approximately 3:00 p.m. The SSD said Resident #8 scored an eight

on her most recent BIMS assessment. She said because the resident scored an eight on the assessment,

the SSD determined the resident was unable to use the call bell. The SSD said she would reassess the resident later in the day.

The SSD was interviewed again on 7/11/24 at 4:04 p.m. The SSD said she reassessed the resident and determined the resident was able to use a call bell. She said she gave the resident a bell.

IV. Shower rooms

A. Observations and interviews

On 7/10/24 at approximately 2:30 p.m., the men's and women's shower rooms on the memory care unit did not have a working call light system. There was a small red button on the men's side of the shower room which read emergency. However, when pushed, the red button did nothing.

CNA #2 was interviewed on 7/10/24 at approximately 2:30 p.m. CNA #2 said the shower room call light initiated a light on a panel that was located across from the nurse's station. She tested the red button and the light on the panel did not light up. She said the facility did not have a different system in place to call for assistance.

The maintenance supervisor (MS) was interviewed on 7/11/24 at 2:43 p.m. The MS said he had worked at

the facility for four years. He said during that time there had never been call lights in the shower rooms on

the memory care unit. He said the red button in the shower room was from an old call light system that no longer functioned.

The MS was interviewed again on 7/11/24 at 3:15 p.m. The MS said he was able to put call lights into the shower rooms (on 7/11/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 48 065100