Durango Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Durango Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 11, 2021

  Based on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#52 and #51) of five residents reviewed for pressure ulcers out of 34 sample residents. Resident #52 was admitted to the facility with intact skin, and no pressure ulcers, and developed multiple areas of skin breakdown to her buttocks, perineal area, heels and ankles. The facility failed to consistently and accurately assess and monitor the resident's skin and provide adequate pressure-relieving interventions. As a result, Resident #52 developed multiple pressure areas, some of which had healed. […]

• Actual harm, isolatedF689Nov 11, 2021

  Based on record review and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for two (#38,#72) residents of six residents reviewed for falls and accidents out of 34 sample residents. Resident #38 who had severe cognitive deficits and resided on the facility's memory care unit (MCU), resulting in four falls in four months. One of the falls, which occurred on 8/4/21, resulted in harm to the resident. Due to a deep laceration to her right outer hand, Resident #38 required transport to the local emergency room for stitches. […]

• Actual harm, isolatedF684Mar 10, 2021

  Based on interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#1) out of 10 sample residents reviewed for unnecessary medications. Resident #1 was administered [MEDICATION NAME] (an antianxiety psychoactive medication) on 11/13/2020. The resident was given 1 ML (milliliters), which was four times the ordered dose. On 11/14/2020, Resident #1, again was administered four times the ordered dose of [MEDICATION NAME] ([MEDICATION NAME]), in [MEDICATION NAME] with [MEDICATION NAME] (liquid opioid) 0.5 ML. Following the initial excess dose of [MEDICATION NAME] on 11/13/2020, Resident #1 suffered a decrease in appetite from an average of 25% to 75% meal intake, to 0% meal intake. […]

• Actual harm, isolatedF744Mar 10, 2021

  Based on interviews, observations and record review, the facility failed to ensure three (#1, #5 and #4) of four out of 10 sample residents who displayed or were diagnosed with [REDACTED]. Specifically, the facility failed to: -Develop a comprehensive plan of care, to include person-centered interventions of dementia care services to address the behaviors for Residents #1, #5 and #4; - The facility failed to provide a person-centered approach to Resident #1's dementia care services to address his physically aggressive behavior in order to prevent physical altercations with other resident's on the secured unit, and -The facility failed to provide person-centered approaches to Resident #4 for therapeutic programming and exhibited behaviors. […]

• Actual harm, isolatedF760Mar 10, 2021

  Based on record review and interviews, the facility failed to ensure three (#1, #8 and #7) out of 10 sample residents were free of significant medication errors. Specifically, the facility failed to: -Ensure Resident #1 was not administered two to four times the physician ordered dose of a psychoactive medication on two occasions; and -Ensure the medication administration record (MAR) and controlled substance administration record matched when a controlled substance was administered to Resident #8 and #7. Following the initial excessive dose of [MEDICATION NAME] on 11/13/2020, Resident #1 suffered a decrease in appetite from an average of 25% to 75% meal intake, to 0% meal intake. […]