Rocky Mountain Care - Logan

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 3 out of 46 sampled residents, a resident experienced a change in condition after a fall, was not provided treatment for 2.5 hours, and ended up passing away. Another resident complained of hip pain after a fall and was not sent to the hospital for 10 hours. These examples will be cited at harm. In addition, a resident was not provided treatment when he was experiencing low oxygen saturation levels. Resident identifiers: 74, 86, and 90.

Inspectors wroteBased on interview and record review, the facility did not ensure that 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 46 sampled residents, a resident was admitted to the facility with surgical wounds and Moisture Associated Skin Damage (MASD) and was discharged with a stage 4 pressure ulcer. This example will be cited at a harm level. Resident identifier: 89.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 46 sampled residents, a resident sustained a fall with a head injury while left unsupervised in the shower. This will be cited at a harm level. Additionally, a resident was involved in a motor vehicle accident that resulted in injuries while being transported in the facility vehicle, and the facility hot water temperatures registered as high as 130 degrees inside resident rooms. Resident identifiers: 32 and 44.

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, expired items in dry storage, expired items in the resident refrigerator, and the sanitizer bucket was not testing at the required sanitation levels.

Inspectors wroteBased on interview and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence of a thorough investigation. Specifically, for 9 out of 46 sampled residents, residents with fractures, a motor vehicle accident involving a resident, allegations against staff regarding care and abuse, a resident that self harmed, and an allegation against a spouse of abuse were not thoroughly investigated to determine if there was abuse or neglect. Resident identifiers: 32, 38, 86, 87, 88, 91, 92, 93, and 95.

Inspectors wroteBased on observation, interview, and record review, 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 disease and infections. Specifically, for 3 out of 46 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for a resident with a feeding tube, a resident did not have EBP signage or supplies in their room, and cross contamination occurred during lunch when staff fed a resident a sandwich with their bare hands. Resident identifiers: 1, 9, and 47.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately to the State Survey Agency (SSA). Specifically, for 1 out of 46 sampled residents, a resident was involved in a motor vehicle accident that resulted in injuries while being transported in the facility vehicle and the incident was not reported to the SSA. Resident identifier: 32.

Inspectors wroteBased on interview and record review, the facility did not permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the health or safety of an individual in the facility was endangered; the licensee ceases to operate the facility; the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; the transfer or discharge was appropriate because the resident's health has improved sufficiently so the resident no longer needed the services provided by the facility; or the transfer or discharge was necessary for the resident's welfare and the resident's needs cannot be met in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the services provided met professional standards of quality. Specifically, for 1 out of 46 sampled residents, a resident's percutaneous endoscopic gastrostomy tube did not have the formula bag labeled with the date and time of the formula preparation, or the nurse's initials who initiated the infusion. Additionally, untrained staff were observed to stop and start the tube feeding and connect and disconnect the tube feeding. Resident identifier: 47.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was 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 of use; or in the presence of adverse consequences. Specifically, for 1 out of 46 sampled residents, a resident's medication was administered when it should have been held per the physician ordered parameters. Resident identifier: 2.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident was allowed to call for staff assistance through the call system from the resident's bed. Specifically, for 1 out of 46 sampled residents, a resident's call light was not accessible to the resident while they were in their bed. Resident identifier: 39.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 3 out of 28 sampled residents, resident rooms had cracked and broken drywall, peeling paint, a door handle that sticks, and a loose toilet. Resident identifiers: 18, 24, and 37.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that medication error rates were not five percent or greater. Observations of 25 medication opportunities on 5/8/24, revealed four medication errors which resulted in a 16% medication error rate. Specifically, for 4 out of 28 sampled residents, medications that were supposed to be taken at least 30 minutes before meals were given to the residents after they had consumed a meal. Resident identifiers: 23, 33, 51, and 69.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had evaluated and determined that the resident's right to self-administer medications was clinically appropriate. Specifically, for 1 out of 28 sampled residents, medications were found at a resident's bedside and the resident had not been evaluated to self-administer their medications. Resident identifier: 43. Findings Included: Resident 43 was admitted to the facility on [DATE] with the following diagnoses of polyneuropathy, dementia, gastro-esophageal reflux disease without esophagitis, major depressive disorder, morbid severe obesity due to excess calories, and asthma. On 5/6/24 at 2:12 PM, an interview was conducted with resident 43's family member. An observation was made of two medications inside of a medicine cup located on top of resident 43's bedside table. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that the resident assessment accurately reflected the resident's status. Specifically, for 1 out of 28 sampled residents, the facility coded a resident as having received insulin during the seven day Minimum Data Set (MDS) observation period when the resident had not received any insulin. Resident Identifier: 14. Findings Included: Resident 14 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to internal left knee prosthesis subsequent encounter, type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus without complications. Resident 14's medical record was reviewed from 5/6/24 through 5/9/24. Resident 14's admission MDS assessment dated [DATE], was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 out of 28 sampled residents, a resident with a respiratory illness experienced a delay in getting their illness treated timely. Resident Identifier: 43. Findings Included: Resident 43 was admitted to the facility on [DATE] with the following diagnoses of polyneuropathy, dementia, gastro-esophageal reflux disease without esophagitis, major depressive disorder, morbid severe obesity due to excess calories, and asthma. On 5/6/24 at 2:12 PM, an interview was conducted with resident 43's Family Member (FM). The FM stated resident 43 had not been feeling well since Friday. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident with limited range of motion (ROM) 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 28 sampled residents, a resident with limited range of motion was not given restorative nursing services that was recommended by physical therapy (PT) to prevent further decrease in range of motion. Resident Identifier: 37.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 28 sampled residents, a resident that had a recommendation for Liquacel twice a day (BID) for wound healing and increased protein needs had the Liquacel order implemented daily and the Liquacel was unavailable for four administrations. Resident identifier: 18.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 28 sampled residents, a resident was not administered their supplement for wound healing and increased protein needs as ordered by the physician due to the supplement not being available. Resident Identifier: 18.

Inspectors wroteBased on interview and record review, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director (MD), and the Director of Nursing (DON) were acted upon. Specifically, for 1 out of 28 sampled residents, a pharmacy recommendation to discontinue a statin medication that may cause myopathy and rhabdomyolysis if administered concomitantly with daptomycin was not acted upon timely when the physician agreed to the recommendation. Resident identifier: 18.

Inspectors wroteBased on observation and interview it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, there were scuff marks, with pieces of drywall missing in rooms, soiled areas, missing trim, broken window blinds, soiled wheelchair and broken cabinets. Resident identifiers: 7, 43 and 54.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide 5 of 29 sampled residents with appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living which included bathing. Specifically, a resident was not provided restorative nursing services that were recommended by therapy and residents were not showered according to their scheduled shower days. Resident identifiers: 7, 26, 41, 50 and 54.

Inspectors wroteBased on interview and record review it was determined, for 2 of 29 sampled residents, that the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a discharged resident's Minimum Data Set (MDS) assessment had not been completed and submitted timely. In addition, a resident's MDS assessment stated he had no dental issues when he actually had dentures. Resident identifiers: 1, 43.

Inspectors wroteBased on interview and record review it was determined, 1 of 29 sampled residents, the facility did not provide a resident who was unable to carry out activities of daily living received necessary services to maintain good grooming and personal hygiene. Specifically, a resident was not provided showers. Resident identifier: 43.