Rocky Mountain Care - Cottage on Vine

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, a resident had left the facility and was unaccounted for approximately 18 hours before management was alerted. Resident identifier: 3Findings included:Resident 3 was admitted to the facility on [DATE] and discharged on 5/28/25 with diagnoses which included sequelae of cerebral infection, injury of left kidney, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Resident 3's medical record was reviewed on 11/5/25. [...]

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was undated food in the refrigerator and freezer, the dietary manager was not wearing a hair net, and the dish machine and sanitizer buckets were not testing at the required levels.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were free from significant medication errors. Specifically, for 3 out of 27 sampled residents, a dialysis resident did not receive his phosphate binding medication with meals as ordered, a resident with a chronic wound and osteomyelitis did not receive his scheduled intravenous (IV) antibiotic medication as ordered, and a resident's seizure medication was not held when ordered by the provider. Resident identifiers: 11, 21, and 41.

Inspectors wroteBased on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 4 out of 27 sampled residents, the residents did not have laboratory results filed in their medical record. Resident identifiers: 3, 12, 15, and 25.

Inspectors wroteBased on observation, interview, and record review, the facility did not follow menus that met the nutritional needs of residents in accordance with established national guidelines. Specifically, correct portion sizes were not provided to residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically, for 1 out of 27 sampled residents, a resident was observed to have medications in her closet and was not evaluated to determine if they were safe to self-administer medications. Resident identifier: 25.

Inspectors wroteBased on interview and record review, the facility did not notify and consult with the physician when there was a need to alter the resident's treatment. Specifically, for 2 out of 27 sampled residents, a resident's suprapubic catheter order was changed and the physician was not notified. Additionally, a resident's intravenous antibiotic was not administered per the physician ordered times and the physician was not notified. Resident identifiers: 3 and 41.

Inspectors wroteBased on interview and record review, the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 1 out of 3 sampled residents, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated. Resident identifier: 100.

Inspectors wroteBased on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 1 out of 27 sampled residents, it was observed that the resident's shower had a bad odor, black substance along the grout lines, white buildup on tile surfaces, and circular red rings along the shower floor. Resident identifier: 23.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made to the Administrator (ADM) of the facility, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, for 1 out of 27 sampled residents, a resident reported an allegation of verbal abuse to a staff member and that information was not reported to the facility ADM, the SSA, or APS. Resident identifier: 10.

Inspectors wroteBased on interview and record review, the facility in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, for 2 out of 27 sampled residents, two allegations of abuse/neglect by staff members were not thoroughly investigated. Resident identifiers: 200 and 201.

Inspectors wroteBased on interview and record review, when the facility transfers a resident, the facility must ensure that the transfer is documented in the resident's medical record and the appropriate information was communicated to the receiving health care institution or provider. Specifically, for 2 out of 27 sample residents, residents that were transferred to the hospital were not sent with necessary documentation to ensure a safe and effective transition of care. Resident identifiers: 28 and 41.

Inspectors wroteBased on observation, interview, and record the review, the facility did not ensure that residents who were continent of bladder received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain. In addition, the facility did not ensure that residents with urinary catheters received services based on the resident's comprehensive assessment. Specifically, for 2 out of 27 sampled residents, a resident that was assessed as a candidate for scheduled toileting was not on a toileting program and a resident with a suprapubic catheter did not have the correct size inserted per physician orders. Resident identifiers: 3 and 99.

Inspectors wroteBased on interview and record review, the facility did not provide routine and emergency drugs to its residents. Specifically, for 1 out of 27 sampled residents, a resident that was prescribed a medication to manage neuropathic pain did not have the medication available for administration due to pending delivery. Resident identifier: 28. Findings Included: Resident 28 was admitted to the facility on [DATE] with diagnoses which included, but were not limited, to neuropathy, osteomyelitis, type 2 diabetes mellitus, left leg below knee amputation, right toe amputation, and epilepsy. Resident 28's medical record was reviewed on 3/3/2025 through 3/6/2025. On 3/3/25 at 9:44 AM, an interview was conducted with resident 28. Resident 28 stated that she was concerned that the facility did not always have medications in stock. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who used psychotropic drugs received behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. In addition, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days. Specifically, for 1 out of 27 sampled residents, a resident taking medications for Post-Traumatic Stress Disorder (PTSD), insomnia, night terrors, and anxiety did not have behavior tracking or adverse side effect (ASE) tracking for those medications. In addition, the resident was prescribed a PRN psychotropic that was extended beyond 14 days without a practitioner justification. Resident identifier: 45.

Inspectors wroteBased on interview and record review, the facility did not have an infection prevention and control program that included a system to monitor antibiotic use for the antibiotic stewardship program. Specifically, for 1 out of 27 sampled residents, a resident's urinalysis and urine culture and sensitivity was not completed. Resident identifier: 12.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident was offered the influenza and pneumococcal immunizations, had the opportunity to refuse the immunizations, and that the documentation indicated that the resident was offered education about the benefits and potential side effects of the immunizations and either received or declined the immunization. Specifically, for 2 out of 5 sampled residents, a resident had a signed consent form for the pneumococcal vaccine but the form did not contain any other documentation, and a resident had a signed consent form for the pneumococcal vaccine that indicated he wished to receive the vaccine but no other documentation was contained on the form. Resident identifiers: 19 and 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, for 1 out of 11 sampled residents, a resident who had psychological needs and multiple falls did not have a care plan for mental health or falls developed. Resident identifiers: 10.

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 of 11 sample residents had a care plan that was revised by the interdisciplinary team. Specifically, a resident had repeated behaviors that were not care planned, including interventions that should be taken by staff to prevent behaviors. Resident identifiers: 1 and 3.

Inspectors wroteBased on interview and record review it was determined, for 1 of 11 sampled residents, that each resident did not receive adequate supervision to prevent accidents. Specifically, a resident's neurological assessments were not completed after sustaining falls. Resident identifier: 10.

Inspectors wroteBased on interview and record review, it was determined for 1 of 11 sampled residents that the facility did not ensure the needed behavioral health care services were provided to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident was not offered behavioral health care services who was admitted with psychological diagnoses and after she was suspected of self harm. Resident identifier: 10.

Inspectors wroteBased on record review and interview it was determined, for 1 of 11 sampled residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, the facility was not documenting progress notes timely and notes were not being documented into the medical record by the staff directly involved in the resident's care. Resident identifiers: 10.

Inspectors wroteBased on observation, interview and record review it was determined, for 8 out of 20 residents sampled, that 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, including COVID-19. Specifically, during a COVID-19 outbreak the facility did not perform contact and droplet precautions for COVID-19 positive residents; perform hand hygiene upon exit of a COVID-19 positive rooms; post notification to visitors that the facility was in a COVID-19 outbreak; utilize disposable utensils and dishware for COVID-19 positive residents; and isolate, transport, and launder COVID-19 positive residents linen's separately. Resident identifier 4, 8, 15, 16, 17, 18, 19, and 20.

Inspectors wroteBased on record review and interview it was determined, for 4 out of 20 residents sampled, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). In addition, report the results of all investigations to the SSA within 5 working days of the incident. Specifically, the facility did not report allegations of abuse within 2 hours of the incident. Resident identifiers: 2, 4, 5 and 9.

Inspectors wroteBased on interview and record review it was determined, for 3 of 20 residents sampled, that the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents did not receive assistance with showers per their preferred shower schedule. Resident identifier 3, 6, and 13.

Inspectors wroteBased on interview and record review it was determined, for 3 of 20 residents sampled, that the facility did not ensure 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, residents did not receive assistance with showers. Resident identifier 3, 6, and 13.

Inspectors wroteBased on observation and interview, the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles and included appropriate accessory instructions and the expiration date when applicable. Specifically, narcotics were repackaged into the narcotic cards.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 20 sampled residents, that the facility did ensure the residents' right to a dignified existence. In addition, 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 resident had his catheter back flushed and then changed without his consent. Resident identifier: 8.

Inspectors wroteBased on observation and interview, for 1 of 20 sampled residents, the facility did not ensure maintenance services were provided to support safe daily living. Specifically, a resident's toilet and toilet seat were not secured to the floor and to the base causing it to move during use. Resident identifier: 14.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 20 sampled residents, that the facility did not ensure that residents remained free from abuse. Specifically, staff witnessed a male resident grope a female resident's breast under her clothing. Resident identifier 6 and 7.

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a nurse misappropriated narcotic medications from a resident after they had expired. Resident identifier: 10.

Inspectors wroteBased on interview and record review it was determined, for 1 of 5 sampled residents, that the facility did not ensure that before offering the pneumococcal immunization, that the resident or the resident representative received education regarding the benefits and potential side effects of the immunization; and the medical record included documentation that the education was provided; and that the resident either received or refused the immunization. Specifically, the resident records did not contain a signed declination or education for the pneumococcal vaccine. Resident identifier 6.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 of 15 sampled residents, facility did not promptly respond with resident presented with signs and symptoms of a UTI and they did not ensure the resident received antibiotics timely, resulting in the resident being sent out to a local hospital for treatment. This will be at a HARM level. Resident identifier: 2.

Inspectors wroteBased on interview and record review, it was determined, the facility did not provide or obtain laboratory (lab) services to meet the needs of its residents. Specifically, for 2 of 15 sampled residents, a urinalysis took multiple attempts and the lab used did not supply all the orders needed for a culture and sensitivity, which resulted in residents not receiving antibiotics timely, and the residents being sent out to a local hospital for treatment. This will be at a HARM level. Resident identifier: 2, 11.

Inspectors wroteBased on interview and record review it was determined that for 1 of 15 sampled residents, that in response to reporting on allegations of abuse, neglect, exploitation, and mistreatment, the facility did not have evidence that the alleged violations were thoroughly investigated. Specifically, when a resident eloped from the facility, a complete investigation was not conducted to ensure the resident's safety and a future elopement would not occur. Resident identifier: 6.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 15 sampled residents received adequate supervision and assistive devices to prevent accidents. Specifically, a resident eloped from the facility. Resident identifier: 6. Resident 6 was admitted to the facility on [DATE] with diagnoses that included dementia, type 2 diabetes, muscle weakness, and need for assistance with personal care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 29 sampled residents, a resident that was unable to reposition on their own and was not frequently repositioned by staff developed a pressure ulcer. Resident identifier: 21.

Inspectors wroteBased on interview and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 29 sampled residents, a resident who was a two-person assist with bed mobility was rolled out of bed and sustained a rib fracture during a brief change with one staff member. Resident identifier: 11.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility failed to provide a risk and benefits of bed rails to the resident or resident representative and obtain informed consent prior to installation. Specifically, for 1 out of 29 sampled residents, a resident with half bedrails attached to the bed was not provided a risk and benefits. Resident identifier: 24.

Inspectors wroteBased on interview and record review, it was determined, the facility did not provide or obtain laboratory (lab) services to meet the needs of its residents. Specifically, for 2 out of 29 sampled residents, a urinalysis took multiple attempts and 22 days before results were reported back to the facility, and a resident did not have ordered labs completed. Resident identifiers: 11 and 26.

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 pneumococcal immunization; and that the resident either received the pneumococcal immunizations or did not receive the pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 2 out of 29 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: 24 and 32.

Inspectors wroteBased on interview and record review, it was determined for 7 of 39 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, one resident with severe cognitive impairment was found to be hitting and spitting on other residents. Additionally, interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. NOTICE: [...]

Inspectors wroteBased on record review and interview it was determined for 7 of 39 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, reports of multiple abuse allegations were not submitted to the State Survey in a timely manner.

Inspectors wroteBased on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 7 of 39 sample residents. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to investigate abuse. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 39 sample residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident with a diagnoses of dementia and pica was found with hazardous liquids and foreign objects. This was found to have occurred at an Immediate Jeopardy (IJ) level. In addition, a resident sustained an injury during a transfer with a Hoyer lift. This was found to have occurred at a harm level. Resident identifiers: 11 and 29. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); [...]

Inspectors wroteBased on observation, interview, and record review, it was determined, for 3 of 39 sample residents, that the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was found to be at a harm level. Specifically, the facility was unable to demonstrate development and implementation of interventions for managing resident's dementia with behavioral disturbances. Resident identifiers: 9, 29 and 41.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not exercise reasonable care for the protection of the resident's property from loss or theft or provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the facility did not have an effective system in place to protect resident's property, including clothing, from loss or theft. In addition, multiple resident rooms had damage to the walls. Resident identifiers: 10, 15, 16, 17, 25, 35, 37, and 42.

Inspectors wroteBased on observations and interview it was determined that, for 11 of 39 sample residents, that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents complained about the palatability of the food, appearance of the food, and repetition of meals. Resident identifiers: 6, 10, 11, 15, 16, 17, 25, 33, 35, 42 and 197.

Inspectors wroteBased on observation, record review and interview it was determined for 1 of 39 sampled residents that 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 infection. Specifically, a nurse was observed to dispose paracentesis fluid in a dumpster, a nurse was observed to not use appropriate hand hygiene during medication pass, and appropriate eye protection was not worn by facility staff. Resident identifiers: 248.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not provide for 3 of 39 sampled residents, with appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, one resident was not provided with assistance as need for communication, and a second resident was not provided assistance on a consistent basis with showers. Resident identifiers: 9, 11, and 29.

Inspectors wroteBased on interview and record review, it was determined that, for 2 of 39 sampled residents, that the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, residents were not provided showers according to their schedules. Resident identifiers: 17 and 35.

Inspectors wroteBased on interview and record review, the facility did not ensure that the medication irregularities reported by the pharmacist were acted upon by the physician and implemented in a timely manner for 1 of 39 sample residents. Specifically, a resident received an anti-coagulation medication for approximately 7 days after the physician discontinued the medication. Resident identifier: 35.

Inspectors wroteBased on interview and record review, it was determined for 1 of 39 sampled residents that the facility did not promptly notify the physician of lab results. Specifically, the physician was not notified of a resident's international normalized ratio (INR) results for the months of April, May and June of 2022. Resident identifier: 33.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 39 sample residents, that the facility did not have reports filed in the resident's clinical record. Specifically, a resident's x-ray report could not be found in his clinical record. Resident identifier: 11.

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 2 out of 5 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: 24 and 35.

Inspectors wroteBased on interview and record review it was determined, for 4 of 8 sampled facility staff members, that the facility did not ensure that routine testing of facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of not up to date vaccinated staff members and exempted staff members, based on the county positivity rate, was not completed. Staff identifiers: Certified Nursing Assistant (CNA) 7, CNA 8, Employee 8 and Licensed Practical Nurse (LPN) 2.

Inspectors wroteBased on interviews and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease- 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 2 of the 5 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal or education of the benefits and potential risks associated with COVID-19 vaccination. Resident identifiers: 24 and 35.