South Platte Rehabilitation and Nursing LLC

In the surveyor’s words

From the most serious findings on record at South Platte Rehabilitation and Nursing LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Oct 15, 2025

  Based on record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for one (#2) of five sample residents reviewed for respiratory care out of 12 sample residents.Resident #2, who was admitted to the facility on [DATE], had a history of chronic obstructive pulmonary disease (COPD - air flow blockage) and required continuous oxygen. On [DATE] at approximately 8:30 a.m. the facility experienced a 45-minute electrical power outage and the backup generator failed to turn on. The social services director (SSD), who was also a certified nurse aide (CNA), transitioned two residents, including Resident #2, from their oxygen concentrators to their portable oxygen canisters when the power went out. […]

• Actual harm, isolatedF600Jan 7, 2025

  Based on observations, record review and interviews, the facility failed to ensure two (#5 and #6) of two residents reviewed for abuse out of eight sample residents were kept free from physical abuse. Resident #4 was admitted to the facility on [DATE] with diagnoses which included alcohol abuse and encephalopathy (brain disease that affects brain function). The resident had a mood problem related to being quick tempered, had poor coping skills and could exhibit verbally aggressive outbursts towards others when he disagreed with them. On 10/21/24, certified nurse aide (CNA) #1 witnessed Resident #4, who was coming inside from the smoking area, purposefully run his wheelchair into Resident #5, who was in the hallway in her wheelchair waiting to go outside to the smoking area. […]

• Actual harm, isolatedF742Jan 7, 2025

  Based upon observations, record review and interviews, the facility failed to ensure that two (#4 and #5) of two residents out of eight sample residents, received the appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Resident #4 was admitted to the facility on [DATE] with diagnoses of alcohol abuse and encephalopathy (brain disease that affects brain function). The resident had a mood problem related to being quick tempered, had poor coping skills and could exhibit verbally aggressive outbursts towards others when he disagreed with them. The facility failed to implement effective interventions for Resident #4 and appropriately address Resident #4's abuse behaviors towards other residents. […]

• Actual harm, isolatedF692Feb 23, 2022

  Based on record review, observation, and interviews, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by significant weight loss for one (#12) of three residents reviewed for nutritional status out of 10 sample residents. Specifically, the facility failed to ensure Resident #12 had interventions in place to prevent significant weight loss. Resident #12 experienced significant weight loss of 11.4% in three months, and 16.4% within a six months' time frame. The registered dietitian (RD) was not aware of the resident's weight loss until February 2022. […]

• No harm, potential for more than minimal, widespreadF812May 18, 2023

  Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food with professional standards for food service safety. Specifically, the facility failed to: -Ensure proper refrigerator temperatures were maintained, and food was properly dated and discarded by the use by date in two out of two unit refrigerators; and, -Ensure sanitary conditions in the dish room. Findings include: I. Ensure proper refrigerator temperatures were maintained, food was properly dated and discarded by the use by date. A. […]