Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Durango Health And Rehabilitation during CMS and state inspections, most recent first.
Two severely cognitively impaired residents in a memory care unit, both with dementia and significant behavioral risk factors, became agitated with each other and engaged in a physical altercation that resulted in a facial scratch to one resident. Facility policy required immediate intervention, separation, and monitoring to prevent abuse, and both residents’ care plans identified risks for aggression, anxiety, and resident-to-resident altercations. Staff reported that only one staff member was assigned to seven residents, that residents often invaded each other’s space, and that fights did occur, including a fist fight between these two residents during the incident in question. The facility’s investigation substantiated the event as physical abuse, demonstrating a failure to protect residents from abuse and to implement effective monitoring and behavioral interventions.
A resident with Alzheimer's disease and severe dementia, identified as high risk for elopement and requiring structured activities, was able to leave the facility unsupervised and remained missing for 49 hours before being found with minor injuries and dehydration. The resident's care plan included interventions for wandering, but the facility's outdated wander guard system and lack of effective supervision allowed the elopement to occur.
A facility failed to inform a resident's MDPOA about the discontinuation of Carbidopa-Levodopa, a Parkinson's medication, for 27 days. The resident, with severe cognitive impairments and diagnosed with Parkinson's disease, experienced a rapid decline after the medication was stopped. Staff interviews revealed a misunderstanding of the notification policy, as the DON believed only changes involving psychotropic medications required notification. This led to a significant lapse in communication and adherence to the facility's policy.
The facility failed to follow the posted menus, serving meals that did not match the planned items, such as substituting broccoli with green beans and altering recipes without informing residents. Residents were not consulted about these changes, leading to dissatisfaction. The dietary manager admitted to recipe alterations and communication issues regarding ingredient availability.
The facility failed to maintain a safe environment, as evidenced by an unwitnessed fall of a resident with an improperly functioning call light, incomplete neurological checks, and lack of care plan updates. Additionally, residents were found with medications and heating devices in their rooms without proper assessments or physician orders, highlighting deficiencies in safety protocols and care management.
The facility failed to inform residents about the duration of their COVID-19 isolation. A resident with severe cognitive impairment was not notified about his isolation period, and there was no documentation in his EMR. Another resident with moderate cognitive impairment was unsure of his isolation end date despite being told verbally. A resident with no cognitive impairment was also not informed, and another resident with moderate cognitive impairment was unaware of the reason for his isolation. Staff interviews indicated a lack of documentation and memory aids for residents.
The facility failed to provide timely and complete Notice of Medicare Non-Coverage (NOMNC) to three residents, resulting in a deficiency. A resident received an incomplete NOMNC lacking the last covered day and appeal information, while two other residents did not receive NOMNC letters upon changes to their Medicare coverage. The oversight was attributed to the previous social services department's failure to issue the notices appropriately.
A long-term care facility was found to have a medication error rate of 10.34%, exceeding the acceptable limit of 5%. Errors included administering the wrong insulin type to a resident, failing to provide Lactaid to a lactose-intolerant resident before giving them dairy, and administering levothyroxine after breakfast instead of on an empty stomach. These incidents were confirmed by the DON and consulting pharmacist.
The facility failed to serve food at palatable temperatures, as reported by several residents who consistently received cold meals. An observation confirmed that food temperatures were below the required 135 degrees F, with the dietary manager acknowledging the ineffectiveness of the current food warming methods.
The facility failed to maintain an effective infection control program, with housekeeping staff not following proper sanitation procedures, residents not offered hand hygiene before meals, and improper disposal of contaminated medication cups. Additionally, the water management plan was outdated and not effectively implemented, lacking documentation of Legionella testing.
The facility failed to ensure CNAs received the required 12 hours of training per year due to the absence of a tracking system. A review showed that two CNAs received only seven and eight hours of training, respectively, in the previous year. The staff development coordinator confirmed the lack of a monitoring system and the shortfall in training hours.
The facility failed to manage the personal funds accounts for two Medicaid-funded residents, resulting in their accounts exceeding the Medicaid eligibility limit. There was no documentation of notifications to the residents or their legal representatives when their accounts approached the limit. Interviews revealed a lack of record-keeping and insufficient assistance in spending down funds.
In a memory care unit, a resident with dementia pushed another, causing a fall, while another resident's medication reduction led to increased aggression, resulting in two altercations. Staff witnessed these events, and investigations confirmed physical abuse. The facility's failure to protect residents from abuse by others was evident.
The facility failed to follow professional standards during medication administration for three residents. An ADON left insulin supplies at a resident's bedside, an RN stored medication in her pocket, and another ADON returned tablets to a stock bottle, risking contamination. These actions violated the facility's medication administration policy.
A resident with multiple medical conditions and specific activity preferences was not provided with meaningful activities or one-to-one visits as per her care plan. Observations showed she was often left without engagement, and interviews revealed her feelings of boredom. The activity director confirmed a lack of documentation for the required visits.
Two residents with diabetes did not receive care according to physician orders and facility protocols. One resident had multiple high blood sugar readings without physician notification, while another experienced delays in rechecking high blood sugar levels, contrary to the hyperglycemia protocol. Interviews revealed staff uncertainty and lack of documentation, indicating a failure in diabetic management.
A resident with severe cognitive impairment and multiple health conditions developed a Stage 2 pressure ulcer due to the facility's failure to implement timely interventions. Observations showed the resident was often without pressure-reducing boots and not repositioned as required. Delays in applying physician-ordered interventions, such as nutritional supplements and pressure-reducing devices, contributed to the deficiency.
A resident with limited range of motion did not receive the recommended restorative nursing services following physical therapy discharge. Despite recommendations for services four to five times per week, the resident only received them six times over several weeks, leading to increased stiffness and a fall. Staff interviews revealed awareness of the resident's decline and acknowledged staffing shortages as a contributing factor.
The facility failed to provide necessary respiratory care for two residents. One resident with severe cognitive impairment and multiple diagnoses, including COPD, was not consistently provided with supplemental oxygen as per physician's orders, resulting in low oxygen saturation levels. Another resident, with moderate cognitive impairments, was performing her own tracheostomy care without proper assessment or observation from staff. Interviews revealed a lack of awareness and assessment regarding the residents' needs for respiratory care.
The facility failed to manage pain for three residents by not establishing parameters for PRN pain medications, leading to inconsistencies in administration. One resident with severe cognitive impairment had inconsistent administration of acetaminophen and hydrocodone-acetaminophen for varying pain levels. Another resident with chronic pain syndrome reported having to request all pain medications, and a third resident with a fracture had PRN medications without established parameters. Staff interviews confirmed the lack of necessary pain parameters.
A resident in an LTC facility was administered the incorrect type of insulin due to a medication error. The ADON gave Humulin R instead of the prescribed insulin lispro, following a high blood sugar reading. The error was linked to insurance issues preventing the use of insulin pens, and the facility's diabetic management policy was not followed.
The facility failed to properly store and label medications, with expired and undated items found in medication carts and storage rooms. Staff interviews revealed lapses in adherence to medication management protocols, highlighting a deficiency in maintaining medication safety and compliance.
A resident with Parkinson's disease was not provided the correct dysphagia advanced diet as prescribed, receiving pureed meals instead. Despite being cognitively intact and having no history of choking, the resident's meal tickets did not match the physician's orders. Staff interviews revealed a breakdown in communication and adherence to dietary procedures, leading to the deficiency.
A facility failed to maintain accurate medical records by destroying a resident's Medical Orders for Scope of Treatment (MOST) forms after the resident's death. The resident, who had a history of heart disease and COPD, changed his code status from full code to DNR during his decline, but the facility did not retain the MOST forms in the electronic medical record. Staff interviews revealed a misunderstanding about the status of MOST forms as part of the medical record, leading to their improper destruction.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse between two cognitively impaired residents in the memory care unit. Facility policy required that residents be free from all forms of abuse and that staff immediately intervene, ensure resident safety, and keep residents separated and monitored when an assailant is identified. Despite this policy, the facility’s own investigation of an incident on 11/26/25 documented that two residents in the memory care unit became frustrated and agitated with each other, with elevated voices and defensive body language, and moved their arms as if they were going to hit each other. One resident sustained a superficial scratch above his left eyebrow, and the investigation concluded that the other resident likely made contact, resulting in the injury, and the incident was substantiated as physical abuse. One resident involved had Alzheimer’s disease and schizophrenia, was severely cognitively impaired with a BIMS score of 1, and required maximum assistance with ADLs. His care plan identified him as being at risk for resident-to-resident altercations related to individuals invading his space and at risk for re‑traumatization, with anxiety triggered by male caregivers or those perceived to be male. Interventions in his care plan included providing opportunities for positive interaction and attention, such as stopping and talking with him while passing by. On the date of the incident, a skin assessment documented a scratch above his left eyebrow, consistent with the facility’s determination that he was the victim of physical abuse by another resident. The other resident involved had Lewy body dementia, hypertension, and depression, was also severely cognitively impaired with a BIMS score of 0, and required maximum assistance with ADLs. His behavior care plan identified a risk for verbally abusive behaviors and potential psychosocial issues due to a prior incident in which he had received unprovoked agitation with physical abuse from another resident, with interventions including monitoring for signs of aggression, fear, or psychosocial trauma and documenting behaviors and interventions. An antipsychotic medication care plan further identified him as being at risk for aggressive behaviors, including non‑redirectable agitation, with instructions to intervene immediately if agitation was observed. Staff interviews indicated that only one staff member was assigned to seven residents on the unit, that residents sometimes got into each other’s space and fights occurred, and that the two residents had been seen in a fist fight on the date of the incident, demonstrating that the facility did not effectively prevent or intervene to stop resident‑to‑resident physical abuse in accordance with its abuse prevention policy and the residents’ care plans.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for one of three residents reviewed for accidents or hazards. Specifically, a resident with Alzheimer's disease and severe dementia, who was identified as being at risk for elopement and required structured activities and distractions from wandering, was able to leave the facility unsupervised. On the day of the incident, the resident was last seen at the nurses' station around 12:45 p.m. and was discovered missing shortly after lunch was delivered to his room. Staff initiated a search of the building and surrounding areas, and the police were notified when the resident could not be found. The resident remained missing for approximately 49 hours before being located within a mile of the facility. Upon being found, the resident had abrasions and required intravenous fluids at the hospital. The resident's care plan had previously identified him as being at risk for elopement and wandering, with interventions such as documenting wandering behavior, providing structured activities, and using reorientation strategies. Despite these interventions, the resident was able to exit the facility without staff knowledge or accompaniment. Interviews with facility staff revealed that the resident was not a typical dementia patient and had a history of wandering and repetitive questioning. The facility had attempted to place the resident in a secured unit prior to the incident, but this led to behavioral issues. At the time of the incident, the facility's wander guard system had not yet been updated as previously agreed upon by the former managing company, which contributed to the resident's ability to elope.
Failure to Notify MDPOA of Medication Change
Penalty
Summary
The facility failed to inform a resident's medical durable power of attorney (MDPOA) about a significant change in the resident's treatment plan, specifically the discontinuation of Carbidopa-Levodopa, a medication used to manage Parkinson's disease. The resident, who had severe cognitive impairments and was diagnosed with Parkinson's disease and neurocognitive disorder with Lewy Bodies, was admitted to the facility with these conditions. The medication was discontinued on December 2, 2024, based on the physician's recommendation, as it was not at a therapeutic level. However, the MDPOA was not informed of this change until December 29, 2024, during a care conference, which was 27 days after the medication was stopped. Interviews with facility staff revealed a lack of communication and understanding of the notification policy. The nurse practitioner stated that the decision to discontinue the medication was made after consulting with the facility's medical director, and the director of nursing (DON) admitted that the nursing staff only notified residents or their MDPOAs of changes involving psychotropic medications. The DON was unaware that the MDPOA needed to be informed of changes in the resident's care, leading to a significant lapse in communication and failure to adhere to the facility's policy on notifying responsible parties of treatment changes.
Failure to Follow Menus and Communicate Substitutions
Penalty
Summary
The facility failed to ensure that the menus were followed to meet the residents' nutritional needs, as observed during meal services. The facility's policy required that menus be planned in advance and served as written unless a substitution was necessary. However, during observations, it was noted that the food items served did not match the posted daily menus. For instance, during a dinner service, the menu listed shrimp scampi with specific sides, but the meal served included plain spaghetti noodles with a thick white sauce and snow peas, deviating from the planned menu. Similarly, during a lunch service, broccoli florets were replaced with green beans without informing the residents or obtaining their consent. Interviews with residents revealed dissatisfaction with the menu substitutions, as they were not informed or consulted about the changes. One resident expressed that they received a meal they had specifically requested not to have, indicating a lack of communication and consideration for resident preferences. The dietary manager admitted to altering the shrimp scampi recipe by adding cream, which was not part of the original recipe, and acknowledged that this change was not communicated to residents or staff. The dietary manager also mentioned that the kitchen's increased production of soups from scratch was affecting the availability of other ingredients, leading to these inconsistencies.
Deficiencies in Resident Safety and Care Plan Management
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for several residents, leading to multiple deficiencies. Resident #7 experienced an unwitnessed fall in the bathroom, where the call light cord was improperly wrapped around a grab bar, rendering it non-functional. Despite the resident's fall, neurological checks were not completed according to the facility's protocol, as the resident was allowed to leave the facility during the 72-hour post-fall assessment period. Additionally, the resident's fall care plan was not updated with new interventions following the incident. Resident #27 was found to have a jar of wart removal medication and eye drops at her bedside without a physician's order or an assessment to determine her ability to self-administer these medications. Furthermore, there was no safety assessment conducted to evaluate her ability to safely use a hot tea kettle with a heating element in her room. Similarly, Resident #11 had a space heater in his room, and Resident #22 had a coffee maker with a heating element, both without documented safety assessments to determine their ability to use these devices safely. Interviews with staff, including registered nurses and the director of nursing, revealed a lack of adherence to protocols and procedures regarding neurological assessments, medication self-administration, and safety assessments for devices with heating elements. The facility's failure to conduct necessary assessments and update care plans contributed to an environment with potential accident hazards, compromising resident safety.
Failure to Inform Residents About COVID-19 Isolation Duration
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the duration of isolation due to COVID-19. Four residents were affected by this deficiency. Resident #4, who had severe cognitive impairment, was not informed about the length of his isolation or when he could leave his room. There was no documentation in his electronic medical record (EMR) indicating that he or his legal representative was notified about the room change or the isolation period. Resident #53, with moderate cognitive impairment, was also not adequately informed about his isolation period. Although he was told verbally that isolation would last for 10 days, he was unsure of the exact date when it would end. A sign indicating the end date of isolation was placed in his room but was not easily visible to him. Despite repeated inquiries, there was no documentation in his EMR confirming that he or his legal representative was informed about the isolation duration. Resident #70, who had no cognitive impairment, expressed concerns about not knowing when his isolation would end. There was no documentation in his EMR indicating that he was informed about the isolation period. Similarly, Resident #41, with moderate cognitive impairment, was not informed about the reason for his isolation or when he could leave his room. Staff interviews revealed that there was a lack of documentation regarding resident education about COVID-19 infections, and memory aids were not provided to assist residents with cognitive impairments in understanding their isolation status.
Failure to Provide Timely and Complete NOMNC
Penalty
Summary
The facility failed to provide timely and complete Notice of Medicare Non-Coverage (NOMNC) to three residents, resulting in a deficiency. Resident #23, who was cognitively intact and required assistance with daily activities due to hemiplegia and hemiparesis, received an incomplete NOMNC. The notice lacked the last covered day and appeal information, which are essential for the resident to understand their coverage and appeal rights. This omission was confirmed by the Social Services Director (SSD), who acknowledged that the resident would not have been able to appeal without the necessary information. Additionally, the facility did not issue NOMNC letters to Resident #81 and Resident #82 upon changes to their Medicare coverage. Resident #81, who was cognitively intact and independent in activities of daily living, was discharged home with home health services but did not receive a NOMNC letter indicating the last covered day of Medicare A services or appeal information. Similarly, Resident #82, who required supervision and assistance with mobility, was discharged without receiving a NOMNC letter. The SSD and Nursing Home Administrator (NHA) confirmed the absence of these notices, attributing the oversight to the previous social services department's failure to issue them appropriately.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 10.34%. This was due to three specific incidents involving medication administration errors. The first incident involved the assistant director of nursing (ADON) #2 administering the wrong type of insulin to a resident. The resident's physician had ordered insulin lispro (Humalog) to be administered according to a sliding scale, but ADON #2 administered Humulin R instead, which was not labeled and not in accordance with the physician's order. The second incident involved a registered nurse (RN) #1 who failed to administer Lactaid to a lactose-intolerant resident before giving them yogurt, which contained dairy. The RN was unable to find the correct dose of Lactaid and proceeded to administer other medications mixed in yogurt, contrary to the physician's order and manufacturer's guidelines. This resulted in the resident not receiving the medication timely or as prescribed. The third incident involved ADON #1 administering levothyroxine to a resident 90 minutes after the scheduled time and after the resident had eaten breakfast. The medication was supposed to be administered on an empty stomach, as per the physician's order and manufacturer's guidelines. These errors were confirmed through interviews with the director of nursing (DON) and the consulting pharmacist, who highlighted the discrepancies in medication administration.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at a safe and appetizing temperature, as required by their policy. The policy, revised in February 2023, mandates that food should be prepared to maintain nutritive value, flavor, and appearance, and served at a palatable temperature to ensure resident satisfaction and minimize risks. However, during a group interview with six alert and oriented residents, it was reported that the food was consistently cold, whether served in the dining room or as a room tray. An observation conducted on April 25, 2024, revealed that a test tray for a regular diet, which was served immediately after the last resident received their room tray, had food temperatures below the palatable threshold of 135 degrees Fahrenheit. The test tray, consisting of shrimp scampi, spaghetti noodles, and snow peas, was plated at 6:10 p.m. and delivered at 7:20 p.m., with temperatures recorded at 123 degrees F for spaghetti noodles, 109 degrees F for snow peas, and 112 degrees F for shrimp scampi. The dietary manager confirmed that the food carts used for passing room trays were not heated, and the plate warmer in the kitchen was ineffective in maintaining the desired food temperature.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Housekeeping staff did not consistently change gloves or perform hand hygiene when appropriate, leading to improper sanitation of resident rooms. Observations revealed that high-touch surfaces, such as call light cords, were not cleaned, and the cleaning process did not follow the recommended procedure of moving from clean to dirty areas. Interviews with housekeeping staff indicated a lack of adequate training and education, with staff reporting minimal orientation and no recent training. Additionally, the facility did not offer hand hygiene to residents before meals, contrary to its own policy. Observations in the main dining room showed multiple residents were not offered hand hygiene before or after eating, despite using their hands to consume food. Interviews with residents and staff confirmed that hand hygiene was not routinely offered, highlighting a significant gap in infection prevention practices. The facility also failed to dispose of contaminated medication pass water cups properly. An RN was observed placing medication cups that had fallen on the floor back onto the medication cart without sanitizing the area. Furthermore, the facility's water management plan was outdated and not effectively implemented. The plan had not been updated since 2021, and there was no documentation of Legionella testing as required by the plan. The NHA admitted to initiating a new water management plan during the survey but lacked evidence of ongoing testing for Legionella.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of training per year, as mandated. Specifically, the facility did not have a system in place to track CNA training hours to ensure compliance with the annual requirement. A review of training records revealed that CNA #9 received only seven hours of training, while CNA #10 received eight hours in the previous calendar year, both falling short of the required 12 hours. During an interview, the staff development coordinator acknowledged the absence of a monitoring system and confirmed the shortfall in training hours for the CNAs.
Failure to Manage Resident Personal Funds Accounts
Penalty
Summary
The facility failed to adequately manage the personal funds accounts for two Medicaid-funded residents, resulting in their accounts exceeding the Medicaid eligibility limit. Resident #2 had $2,354.81 in her account, which was $354.81 over the $2,000 limit, while Resident #30 had $3,683.41, exceeding the limit by $1,683.41. There was no documentation to indicate that the facility had notified either resident or their legal representatives when their accounts reached $200 less than the eligibility resource limit, as required. Interviews with the business office manager (BOM) and the social services director (SSD) revealed that the facility did not maintain records of notifications sent to residents about their account balances. The BOM acknowledged the responsibility to assist residents in spending down their funds and mentioned using a facility Amazon account for this purpose. Despite efforts to help Resident #2 spend her money, her account remained over the limit. The SSD confirmed that the facility could have done more to assist both residents in managing their funds to avoid exceeding the Medicaid eligibility limit.
Failure to Protect Residents from Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect three residents from physical abuse by other residents, as evidenced by multiple incidents in the memory care unit. Resident #42 was pushed by Resident #25, resulting in a fall, while Resident #52 was pushed by Resident #24, causing her to fall back into her wheelchair. Additionally, Resident #24 and Resident #68 were involved in a physical altercation where Resident #24 slapped Resident #68's hand, and Resident #68 retaliated by slapping Resident #24's chest. These incidents were witnessed by staff members who reported them to the appropriate personnel. Resident #25, who has dementia with behavioral disturbances, displayed daily behavioral symptoms directed at others, including hitting and pushing. A gradual dose reduction (GDR) of her anti-anxiety medication was in progress, which was later reversed due to increased aggression. Resident #24, also diagnosed with dementia with behavioral disturbances, was undergoing a GDR of her antipsychotic medication, which was identified as a contributing factor to her increased agitation and aggressive behaviors. Resident #52, who was legally blind and had moderate cognitive impairment, was identified as a moderate fall risk. The facility's investigations into these incidents concluded that physical abuse was substantiated in each case. The investigations revealed that the GDRs for Residents #24 and #25 were contributing factors to the altercations. Despite the facility's policy to prevent resident abuse and provide a safe environment, the incidents occurred, indicating a failure to adequately protect residents from abuse by other residents.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of practice during medication administration for three residents. For Resident #67, the assistant director of nursing (ADON) left an insulin supply box containing insulin and sharps at the bedside after checking the resident's blood sugar. This action was contrary to the facility's policy, which mandates that medications should not be left with the resident. Resident #67 was cognitively intact and had multiple diagnoses, including type 1 diabetes mellitus and functional quadriplegia. For Resident #26, a registered nurse (RN) placed half of an olanzapine tablet in a medication cup and stored it in her pocket, intending to dispose of it later. This practice violated the facility's policy on medication storage. Resident #26 had moderate cognitive impairment and several medical conditions, including type 2 diabetes mellitus and acute respiratory failure. In the case of Resident #29, an ADON returned two 10 mg famotidine tablets to a stock medication bottle after realizing a dosage error, which could lead to contamination. Resident #29 also had moderate cognitive impairment and was diagnosed with chronic respiratory failure and type 2 diabetes mellitus.
Failure to Provide Resident with Individualized Activities
Penalty
Summary
The facility failed to provide a resident with an ongoing program of activities tailored to meet her needs and interests, as outlined in her individualized care plan. The resident, who is under 65 years old, has multiple medical conditions including non-ischemic myocardial injury, heart failure, hemiplegia, hemiparesis following a stroke, and type 2 diabetes with chronic kidney disease. Her assessment indicated preferences for activities such as interacting with animals, going outside, reading, listening to music, and keeping up with the news. Despite these preferences, observations revealed that the resident was often left in her room without engagement in any activities, such as watching television or listening to music, and no staff were observed providing her with activities during the survey period. Interviews and record reviews further highlighted the deficiency. The resident expressed feelings of boredom and a lack of activities, stating she had not been reading due to illness. The activities care plan, initiated in early May, aimed for weekly one-to-one visits from activities staff, but there was no documentation of these visits or any refusals in the resident's progress notes for May and June. The activity director confirmed the lack of documentation and noted that the resident had been refusing visits since her health declined. The director also acknowledged the need for improved documentation and had begun training staff on documentation expectations.
Failure to Follow Diabetic Management Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and the comprehensive person-centered care plan for two residents with diabetes. Resident #58, who was cognitively intact and diagnosed with type 2 diabetes mellitus, had several instances of high blood sugar readings that exceeded the physician-ordered parameters. Despite the facility's policy requiring physician notification for blood sugar levels above 400 mg/dl, there was no documentation of such notifications for multiple high readings in January, February, and May 2024. Resident #67, also cognitively intact and diagnosed with type 1 diabetes mellitus, experienced numerous high blood sugar readings over 400 mg/dl in June 2024. The facility's hyperglycemia protocol required rechecking blood sugar every hour and notifying the physician for readings above 400 mg/dl. However, the records showed significant delays in rechecking blood sugar levels, sometimes spanning several hours, and no documentation indicated that the hyperglycemia protocol was followed during this period. Interviews with the facility's nursing staff revealed a lack of adherence to the hyperglycemia protocol. The Assistant Director of Nursing was unsure about the required time frame for rechecking blood sugar levels, while the Director of Nursing acknowledged that the protocol was not followed as per the physician's orders. The DON admitted that there was no documentation of follow-up actions for high blood sugar readings, indicating a systemic issue in monitoring and managing diabetic care for these residents.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for a resident, leading to the development of a Stage 2 pressure injury on the resident's right lateral ankle. The resident, who was under 65 years old and had severe cognitive impairment, was admitted with multiple health conditions including non-ischemic myocardial injury, heart failure, hemiplegia, and diabetes with chronic kidney disease. Despite these conditions, the resident was not initially identified as being at risk for pressure ulcers, and the facility did not implement necessary interventions to prevent pressure injuries. Observations revealed that the resident was often left without pressure-reducing boots, which were part of the prescribed care to offload pressure from the feet and ankles. The resident was observed lying on her right side for extended periods without repositioning or the use of pressure-reducing devices, contrary to the facility's policy and physician's orders. The facility's failure to apply pressure-reducing boots and ensure proper positioning contributed to the development of the pressure injury. The facility's records and staff interviews indicated delays in implementing physician-ordered interventions, such as nutritional supplements and pressure-reducing boots, which were not put in place until several days after the pressure injury was identified. Additionally, the facility's care plan lacked nutritional interventions for pressure injury prevention or healing, and there was a lack of documentation and follow-up on the resident's nutritional needs. These oversights and delays in care contributed to the resident's pressure injury and highlighted deficiencies in the facility's pressure ulcer prevention and care practices.
Failure to Provide Recommended Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate restorative nursing services to a resident with limited range of motion, as recommended by physical therapy. The resident, who was over 65 years old and diagnosed with dementia, Parkinson's disease, and anemia, had completed physical therapy goals by May 2024. The discharge summary from physical therapy recommended a restorative nursing program to maintain the resident's current level of function, including restorative ambulation and range of motion exercises. However, the facility did not implement these services in a timely manner, with a delay of 20 days before the resident began receiving restorative nursing services. The resident expressed concerns about increased stiffness and difficulty in movement, attributing a recent fall to a decline in physical strength due to the lack of restorative services. Despite the physical therapy recommendation for services four to five times per week, the resident only received these services six times between late May and mid-June 2024. The facility's failure to offer the recommended frequency of restorative nursing services was compounded by the resident's COVID-19 diagnosis, during which time services were put on hold without being offered in the resident's room. Interviews with staff, including a registered nurse, a CNA, the MDS coordinator, and the DON, revealed awareness of the resident's increased need for assistance and the importance of following physical therapy recommendations. The MDS coordinator acknowledged that the reduction in restorative services was due to staffing shortages, which may have contributed to the resident's decline in physical function. The DON confirmed that restorative services should have been provided even during the resident's COVID-19 infection, indicating a lapse in adherence to recommended care protocols.
Deficiencies in Respiratory Care and Assessment
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for two residents. Resident #4, who had severe cognitive impairment and multiple diagnoses including COPD and chronic respiratory failure, was not consistently provided with supplemental oxygen as per physician's orders. Observations revealed that Resident #4 was often without an oxygen cannula, despite having low oxygen saturation levels, sometimes as low as 69%. Staff failed to ensure the resident received oxygen therapy consistently, and there was a lack of documentation and communication with the physician regarding the resident's low oxygen saturation levels. Additionally, the facility did not adequately assess Resident #3's ability to perform tracheostomy care independently. Despite having moderate cognitive impairments, Resident #3 was performing her own tracheostomy care without any assistance or observation from the nursing staff. The facility failed to conduct a proper assessment to ensure that Resident #3 could safely perform this care, as there was no direct observation or return demonstration documented. Interviews with staff revealed a lack of awareness and assessment regarding the residents' needs for respiratory care. CNA #1 and RN #2 acknowledged that Resident #4 often removed his oxygen, but there was no consistent effort to ensure he wore it as required. Similarly, RN #3 and RN #1 were unaware of any assessment of Resident #3's ability to perform tracheostomy care safely. The facility's failure to provide appropriate respiratory care and assessments for these residents highlights significant deficiencies in their care practices.
Failure to Establish PRN Pain Medication Parameters
Penalty
Summary
The facility failed to manage pain for three residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not establish parameters for as-needed (PRN) pain medications for three residents. This deficiency was identified through interviews and record reviews. Resident #57, who had severe cognitive impairment and multiple diagnoses including lumbar radiculopathy and lumbar spondylosis, had physician orders for acetaminophen and hydrocodone-acetaminophen for pain management. However, the orders did not specify when to administer each medication based on the resident's pain level. The medication administration record showed inconsistencies in the administration of these medications for varying pain levels, and the physician's progress note with pain parameters was not reflected in the orders. Resident #58, who was cognitively intact and had chronic pain syndrome, also had multiple PRN pain medications ordered without specific parameters. The resident reported having to request all pain medications and expressed concerns about not receiving medications automatically. Similarly, Resident #11, who had a fracture and other conditions, had PRN pain medications ordered without established parameters. Staff interviews confirmed the lack of pain parameters, which are necessary to ensure the correct medication is administered based on the resident's reported pain level.
Medication Error: Incorrect Insulin Administered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The assistant director of nursing (ADON) administered the incorrect type of insulin to a resident. The physician's order specified the use of insulin lispro (Humalog) to be administered according to a sliding scale based on the resident's blood sugar levels. However, the ADON administered Humulin R, a different type of insulin, which was not labeled with a pharmacy label. This error occurred after the ADON obtained a blood sugar reading indicating the resident's blood sugar was over 600 mg/dl and proceeded to administer eight units of Humulin R instead of the prescribed insulin lispro. The error was attributed to the resident's insurance not covering the insulin pens, leading the facility to use Humulin R from a vial. The ADON acknowledged the mistake and noted that the physician should have been notified to change the order. Interviews with the director of nursing (DON) and the consulting pharmacist confirmed the error, highlighting the difference in the action times between the two types of insulin. The facility's diabetic management policy and professional standards emphasize the importance of administering medications as prescribed, which was not adhered to in this instance.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During observations, it was found that two of the six medication carts and one of the two medication storage rooms contained improperly labeled and expired medications. Specifically, an open Tresiba FlexTouch Pen-injector was not labeled with the date it was opened, and an open bottle of isopropyl alcohol had expired. Additionally, several expired medications, including multivitamins, esomeprazole magnesium, vitamin B12, loperamide HCL, spironolactone, omeprazole, and furosemide, were found in the medication storage room and on the medication carts. Interviews with staff revealed a lack of adherence to proper medication management protocols. An LPN acknowledged that insulin pens should be dated when opened and agreed to dispose of the expired isopropyl alcohol. An RN confirmed that expired medications should be disposed of and mentioned using a drug buster for this purpose. The assistant director of nursing also recognized that the expired package of omeprazole should have been removed from the medication cart. These findings indicate a failure in maintaining medication safety and compliance with professional standards, potentially compromising resident care.
Failure to Provide Correct Mechanically-Altered Diet
Penalty
Summary
The facility failed to provide a resident with the correct mechanically-altered diet as prescribed, leading to a deficiency in dietary care. The resident, a 79-year-old with Parkinson's disease, malnutrition, and GERD, was cognitively intact and required assistance with meal setup and cleanup. Despite being prescribed a dysphagia advanced diet, which includes soft and bite-sized foods, the resident was repeatedly served pureed meals, which did not align with her dietary needs or preferences. Observations revealed that the resident was served pureed food items instead of the prescribed dysphagia advanced diet. The resident expressed dissatisfaction with the pureed food, noting it lacked flavor and was not necessary as she had no history of choking. The facility's dietary records and meal tickets did not reflect the correct diet order, indicating a failure in communication and adherence to the prescribed dietary plan. Interviews with staff, including the SLP and DON, highlighted a breakdown in the process of updating and communicating diet orders. The SLP confirmed the resident's need for a dysphagia advanced diet and noted that the kitchen did not follow the IDDSI framework. The DON acknowledged the discrepancy between the meal tickets and physician's orders, indicating a lack of regular comparison and verification of diet orders. The dietary consultant was unaware of how the incorrect diet change appeared in the resident's profile, suggesting procedural lapses in the dietary department.
Failure to Retain MOST Forms in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the Medical Orders for Scope of Treatment (MOST) forms. The resident, an 80-year-old with a history of atherosclerotic heart disease and chronic obstructive pulmonary disorder, was admitted and later passed away. During the resident's decline, he expressed a desire to change his code status from full code to Do Not Resuscitate (DNR), which was documented and witnessed by two nurses. However, the facility did not retain the initial or amended MOST forms in the resident's electronic medical record (EMR), as they were destroyed following the resident's death. Interviews with facility staff, including the nursing home administrator (NHA), registered nurse (RN), infection preventionist (IP), nurse practitioner (NP), and regional clinical consultant (RCC), revealed a misunderstanding regarding the status of MOST forms as part of the resident's medical record. The NHA and IP believed the MOST forms were not part of the permanent medical record and were destroyed after discharge or death. However, the NP and RCC confirmed that the MOST forms are considered physician's orders and should be retained as part of the medical record. The facility lacked a policy on the destruction of MOST forms, leading to the improper handling of these critical documents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Durango
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottonwood Rehabilitation And Healthcare Center | 3.4 mi | — | 1 | 0 |
| Valley Rehabilitation And Healthcare Center, The | 22.8 mi | — | 3 | 0 |
| Aztec Healthcare | 33 mi | — | 5 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Durango Health And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.