Rocky Mountain Care- Clearfield

Inspectors wroteBased on observation, interview, and record review, the facility did not treat each resident with respect, dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, for 2 out of 54 sampled residents, staff were not provided education on how to attach a resident's prosthetic arm, and a resident was seated at a table that was at her chin height for breakfast. The first example was cited at harm. Resident identifiers: 21 and 63.

Inspectors wroteBased on observation, interview, and record review, for 3 of 54 sampled residents, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, Enhanced Barrier Precautions (EBP) were not implemented for a resident receiving wound care, and an observation was made of cross-contamination between residents during meals. Additionally, a resident's tube feeding formula was not capped when disconnected from the resident. Resident identifier: 2, 4, and 8. Finding Included:1. [...]

Inspectors wroteBased on observation, interview, and record review, for 2 of 54 sampled residents, the facility did not ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs), including hygiene and dining. Specifically, a resident with visual impairment was not provided assistance with dining and another resident was not provided assistance with bathing. Resident identifiers: 4 and 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out activities of daily living. Specifically, for 1 out of 54 sampled residents, a resident was not provided showers as scheduled. Resident identifier: 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 1 out of 54 sampled residents, a resident's range of motion decreased with restorative nursing services after the resident was discharged from physical therapy. Resident identifier: 1.

Inspectors wroteBased on interview and record review, the facility did not immediately inform a resident's representatives after an accident, which resulted in injury and required physician intervention for 1 of 12 sampled residents. Specifically, when a resident had a fall, sustained a femur fracture, and required hospitalization, staff did not attempt to notify additional resident representatives when the primary contact did not answer the telephone. Resident identifier: 3.

Inspectors wroteBased on interview and record review it was determined that for 1 of 55 residents that the facility did not ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. Specifically, a staff member documented a problem with a resident's toe, and it was not addressed by a doctor for 27 days, at which point the toe had become necrotic and surgery was required. Resident identifier: 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and each resident received adequate supervision and assistance to prevent accidents. Specifically, for 4 of 55 sampled residents, a resident was left unsupervised with a damaged bedside table and the resident was observed pulling on the broken plastic with sharp edges; a resident bed was not locked in place resulting in a fall with a finger injury; a resident was being assisted with a transfer by a family member outside, resulting in the resident falling and dislocating a shoulder; and a resident with a history of falls was injured. These findings resulted in a citing of harm for 2 residents. Resident identifiers: 20, 60, 80, and 166.

Inspectors wroteBased on observation and interview, for 4 of 55 sampled residents, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a staff member did not have an appropriate response to a resident statement, a resident was not provided a dignified dining experience and call lights were not answered in a timely manner. Resident identifiers: 12, 20, 50, and 259.

Inspectors wroteBased on observation and interview, it was determined that, for 3 of 55 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, there were multiple instances where the facility was dirty and not homelike. Resident identifiers: 20, 80, and 259. Findings Include: 1. Resident 259 was admitted to the facility initially on 3/13/24, and re-admitted on [DATE] with diagnoses that included cellulitis of the right leg, encephalopathy, chronic respiratory failure with hypercapnia and hypoxia, heart failure, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, and morbid obesity. On 4/9/24 at 9:20 AM, an interview was conducted with resident 259. Resident 259 stated she went out to smoke twice daily. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 3 of 55 sample residents. Specifically, a resident stated they had been abused and not follow up investigation was documented, interviews were not documented with all staff members involved in the investigation, and a through investigation was not conducted. Resident identifier: 79, 82 and 86.

Inspectors wrote3. Resident 60 was admitted [DATE] with diagnoses including end stage renal disease, insomnia unspecified, essential (primary) hypertension, peripheral vascular disease unspecified, other intervertebral disc degeneration lumbosacral region, dependence on renal dialysis, displaced avulsion fracture (chip fracture) of left talus, subsequent encounter for fracture with routine healing, type 2 diabetes mellitus with diabetic polyneuropathy, and dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident 60's medical record was reviewed from 4/8/24 through 4/17/24. Resident 60's most recent Brief Interview for Mental Status (BIMS) Score from her most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] was a 15, indicating no cognitive impairment. [...]

Inspectors wroteBased on interview and record review, for 4 of 55 sampled residents, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene. Specifically, residents requiring assistance with bathing were not provided regular showers or bed baths. Resident identifiers: 2, 34, 82, and 259.

Inspectors wroteBased on interview and record review, the facility did not ensure that for 6 of 55 sample residents, the residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Specifically, residents were being seen by an alternate provider such as a Nurse Practitioner, instead of a physician. Resident identifiers: 19, 46, 49, 62, 102, and 166.

Inspectors wroteBased on interview, observation and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents and staff voiced concern about the staffing level, showers were not provided as scheduled, call lights were not answered timely, and the environment was observed to be soiled. Resident identifiers: 19, 23, 26, 37, 46, 56, 60, 98, 99, 208, 259, and 309.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that all drugs and biological's were labeled in accordance with currently accepted professional principles, were stored under proper temperature controls, and included the expiration date when applicable. Specifically, a resident had insulin pens at bedside with out storage to prevent access to the insulin by other residents. Medication was left at the bedside of a resident who was not assessed for self administration of medication. A multi use vials of medications were opened and available for use date indicated medications were expired and still available for use. The medication fridge indicated temperatures too cold for safe medication storage. Resident identifiers: 15, 21, and 92.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility did not label or date multiple food items in the walk-in fridge and refrigerator, there were physical food contamination hazards present in the kitchen, and kitchen staff did not prepare and serve food in a hygienic manner. Findings Include: On 4/8/24 at 8:54 AM, an observation was made of one of the facility's freezers. Inside was an undated tub of ice cream, a box of open undated Udi buns, undated pie crusts, a package of undated [NAME] Spunkmeyer cookie dough, a bag of undated whipped topping, 7 undated frozen pies, and 2 bags of undated frozen fruit. On 4/8/24 at 8:58 AM, an observation was made of a ceiling vent and the ceiling directly above a food preparation area. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that for 3 of 55 sample residents, medical records were complete and accurately documented. Resident identifiers: 3, 19, and 46.

Inspectors wroteOn 4/17/24 at 3:27 PM an interview with the Administrator was conducted. The Administrator stated that the QAPI team met at least quarterly but tried to meet monthly if possible. The Administrator stated that the QAPI team consisted of the Administrator, the Medical Director, the Dietary Manager, the Director of Nursing, the Resident Advocate, Social Work, Nurse Management, and Therapy. The Administrator stated that every month, members of the QAPI team would bring information including quarterly measures, grievances, infection control updates, among other assignments that the staff go over and determine what areas needed to be improved. The Administrator stated that once an improvement process had begun, monitors were put in place and were checked as needed. [...]

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 3 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' pneumococcal consent status or education of the benefits and potential risks associated with the immunization. Resident identifiers: 3, 15, and 19. Findings Included: 1. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were numerous odors throughout the facility. Findings Include: On 4/8/24 at 10:30 AM an observation was made of the 200 hallway. There was a strong odor of bowel movement throughout the hallway. On 4/8/24 at 11:53 AM, an observation was made of the 300 hallway. There was a strong smell of urine throughout the entire hallway. On 4/10/24 at 8:22 AM, an observation was made of the 400 hallway. There was a strong odor of urine throughout the hallway. On 4/10/24 at 8:32 AM an observation was made in the 100 hallway. There was a strong odor of bowel movement throughout the entire hallway. On 4/10/24 at 8:42 AM, an observation was made of the 400 hallway. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, for 2 out of 55 sampled residents, residents did not receive written notice prior to the room change. Resident identifiers: 166 and 259. Findings Included: 1. Resident 166 was initially admitted to the facility on [DATE] and readmit to the facility on 1/25/2024 with the diagnosis of Periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter, Acute kidney failure, Neoplasm of unspecified behavior of bladder, Fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter, Human immunodeficiency virus [HIV] disease. Resident 166's medical records were reviewed on 4/15/24. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 55 sampled residents, that the facility did not ensure that the resident had the right to send and receive mail including the right to privacy of such communications. Specifically, a resident received two letters via the postal service and facility staff opened the letters. Resident identifier: 26.

Inspectors wroteBased on interview and record review it was determined, for 2 of 55 sampled residents, that the facility did not ensure that the resident's right to formulate an advanced directive, including implementing the advanced directive per the facility policy was completed. Specifically, two residents' electronic medical records (EMR) documented that the residents' code status was Do Not Resuscitate (DNR) when the resident's Provider Order for Life-Sustaining Treatment (POLST) form documented full treatment. Resident identifiers: 19 and 92.

Inspectors wroteBased on observation and interview, it was determined, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 5 out of 37 sampled residents, resident rooms were observed to be unclean with debris on the floor. In addition, Hoyer lifts for resident care were observed to be soiled. Resident identifiers: 7, 19, 26, 62, and 80.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure that residents who are unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 10 out of 37 sampled residents, residents who were dependent on staff for showers, did not receive showers on a consistent and regular basis. Resident identifiers: 19, 26, 29, 32, 54, 62, 63, 80, 81, and 84.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, for 6 out of 37 sampled residents, resident showers were not being completed due to staffing, complaints from residents regarding staffing and not receiving cares, and long call light times were observed. Resident identifiers: 7, 32, 40, 52, 54, and 121.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F584, and F880 which were cited within the facility's 2020 recertification survey. In addition, the facility was found to be in non-compliance with F758 and F761 which were cited within the facility's 2017, 2019, and 2020 recertification survey.

Inspectors wrote2. On 8/1/22 at 8:59 AM, an observation was made of Registered Nurse (RN) 1 and Nursing Student (NS) 1 exiting resident room [ROOM NUMBER] which had signage on the door indicating the resident was on droplet precautions. Door signage also included instructions for donning appropriate PPE and doffing PPE. Both nurses were observed not to sanitize their eye protection after exiting the room. An interview was conducted with RN 1. RN 1 stated that Centers for Disease Control and Prevention guidelines, for residents on quarantine, required staff to don a mask, eye protection, a gown, and gloves before entering a room, and doff the gown and gloves when exiting the room. RN 1 also stated staff should perform hand hygiene after exiting and sanitize the eye protection. RN 1 stated both staff should have sanitized their eye protection and they did not. 3. [...]

Inspectors wroteBased on interview and record review, it was determined, the facility did not review and revise the comprehensive care plan after each assessment. Specifically, for 1 out of 37 sampled residents, the care plan did not address a resident's intravenous (IV) hydration status. Resident identifier: 80.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 out of 37 sampled residents, a percutaneous endoscopic gastrostomy (PEG) tube feeding did not have the bag labeled with the formula type, rate of infusion, resident identification information, date and time of administration, or the nurse initials who initiated the infusion. Resident identifier: 99.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not provide necessary respiratory care and services consistent with the resident's care plan and goals. Specifically, for 1 out of 37 sampled residents, a resident's oxygen tubing and prefilled humidifier bottle were not changed as ordered by the physician, and the filter on the concentrator was not cleaned as ordered by the physician. Resident identifier: 14.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 37 sampled residents, a resident reported uncontrolled pain and missed pain medication administration. Resident identifier: 62.

Inspectors wroteBased on interview and record review, it was determined, the irregularities noted by the pharmacist during the drug regimen review must be reported to the attending physician and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 2 out of 37 sampled residents, a pharmacy recommendation to attempt a gradual dose reduction (GDR) on a resident's medication was not acted upon when the physician agreed with the pharmacy recommendation. In addition, . Resident identifiers: 7 and 62.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure each resident's drug regimen remained free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued. Specifically, for 2 out of 37 sampled residents, a resident's medications were not administered per the physician's orders and medications were omitted and documented as not being administered at all. Resident identifiers: 62 and 80.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 37 sampled residents, a resident received one GDR on an antipsychotic medication for bipolar disorder that was initiated by the facility on 9/1/21. Resident identifier: 7.

Inspectors wroteBased on observation and interview, it was determined, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, observations were made of medications left unattended on top of the medication cart and a medication was found available for use without an expiration date or dosage visible.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not provide the special eating equipment and utensils for residents who needed them. Specifically, for 1 out of 37 sampled residents, the facility did not provide the resident with weighted utensils to assist with dining. Resident identifier: 80.

Inspectors wroteBased on interview and record review it was determined, the facility did not maintain records on each resident that were complete, accurately documented, and readily accessible. Specifically, for 2 out of 37 sampled residents, progress notes for a resident had notes from other residents located inside their medical record, and pharmacy monthly medication reviews were not located in the resident's medical record. Resident identifiers: 62 and 80.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 45 sampled residents, that the facility did not ensure that the medication error rate was not 5 percent or greater. Specifically, 4 medication errors were observed out of 31 observations with a medication error rate of 12.9%. Resident identifiers: 7, 99, and 330.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not determine that the right to self-administer medications was safe and clinically appropriate. Specifically, a resident was observed to self administer insulin incorrectly and the entire dose was not dispensed. Resident identifier: 7.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, residents complained of smoking odors and observations were made of residents smoking in close proximity to the facility.

Inspectors wroteBased on interview and record review, it was determined, for 2 of 45 sampled residents, the facility did not make prompt efforts to resolve grievances the residents may have. Specifically, grievances filed by the residents were not addressed by the facility in a timely manner. Resident identifiers: 6 and 112.

Inspectors wroteBased on interview and record review it was determined, for 2 of 45 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident who did not require an anticoagulant medication was coded as receiving anticoagulants. In addition, a resident with a Preadmission Screening Resident Review (PASRR) Level II was coded as currently not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Resident identifiers: 9 and 64.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident with a contracture did not receive range of motion services in order to prevent further decrease in range of motion. Resident identifier: 80.

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 45 sampled residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, one resident was not provided with assistance and interventions to prevent falls in accordance with her plan of care and a second resident was burned by a steam table located in the dining room. Resident identifiers: 6 and 112.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that the licensed nurses had the specific competencies and skill set necessary to care for the residents' needs. Specifically, an observation was made of Licensed Practical Nurse (LPN) 1 administering intravenous (IV) medications improperly and the LPN did not have the credentials that documented competency in IV infusions. Resident identifier: 330.

Inspectors wroteBased on interview and record review it was determined, for 2 of 45 sampled residents, that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that all drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled. Specifically, the facility did not have a narcotics reconciliation process in place and the Narcotic Record Log did not match the Medication Administration Records (MAR). Resident identifiers: 31 and 50.

Inspectors wroteBased on interview and record review, it was determined the facility did not ensure that as needed (PRN) psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, for 1 of 45 sampled residents, an anti-anxiety drug was not limited to 14 days and the resident's record did not document a rationale for use including a duration for the order. Resident identifier: 112.

Inspectors wroteBased on observation and interview, it was determined that the facility did not label all drugs in accordance with professional standards and with the expiration date, and all drugs and biologicals were not stored under proper temperature controls. Specifically, an opened vial of insulin was not labeled with an expiration date and a medication fridge was not registering within the temperature control range for the stored medication.

Inspectors wroteBased on observation and interview it was determined, for 1 of 45 sampled residents, that the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Specifically, facility staff were observed to bare handed touch medication during medication preparation. Resident identifier: 54.