Rocky Mountain Care - Willow Springs

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 10 sampled residents, notification to the SSA and APS was not done within 2 hours, when facility nursing staff observed a resident's brother kissing the resident on two different occasions Resident identifier: 3. Resident 3 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and acute systolic congestive heart failure. Resident 3's medical record was reviewed on 3/31/26. A review of the facility reported incident revealed that on two different instances resident 3 was observed by facility nursing staff to be kissing her brother on 12/28/25 and 1/4/26. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 10 sampled residents, a resident experienced a change in condition after a fall and was not sent to the hospital timely. Resident identifier: 4. Resident 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, generalized muscle weakness, other abnormalities of gait and mobility, and unspecified atrial fibrillation. Resident 4's medical record was reviewed on 3/31/26. A review of resident 4's progress notes revealed: a. On 12/21/25 at 10:22 PM, an order-administration note documented, .PT [patient] did have a fall around 1940 [7:40 PM] she doesn't remember what happened. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 10 sampled residents, a resident with cognitive impairment eloped from the facility. Resident identifier: 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, ataxia, Wernicke's encephalopathy, alcohol dependence, opioid dependence, and traumatic subdural hemorrhage. Resident 2's medical record was reviewed on 3/31/26. A review of resident 2's elopement risk screening dated 12/5/25 revealed a score of 12 which indicated that resident 2 was at risk for elopement. A review of resident 2's progress notes revealed: a. On 12/5/25 at 10:58 PM, a nurse's note documented, Resident admitted to facility from [local hospital]. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident 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 1 out of 38 sampled residents, a resident who was identified as a two-person assist for bed mobility and incontinence care sustained a fall during a one-person assist for incontinence care. Resident identifier 264. Corrective Action: On 4/8/25, resident was assessed for injury; it was determined resident needed immediate medical attention and was sent to hospital via emergency medical services (EMS). Ensure two people were in the room when moving the resident, this included rolling and Hoyer transfers. Certified Nursing Assistant (CNA) 2 was put on leave until the investigation was completed. [...]

Inspectors wroteBased on interview and record review, the facility did not determine that the resident's right to self-administer medication was clinically appropriate. Specifically, for 1 out of 38 sampled residents, a resident was observed to have in their possession four inhalers for self-administration of the medications. Resident identifier: 58.

Inspectors wroteBased on interview and record review, the facility did not comprehensively assess a resident within 14 days after determining, or should have determined, that there had been a significant change in the resident's physical or mental condition. Specifically, for 1 out of 38 sampled residents, a resident that was admitted to hospice services did not have a significant change Minimum Data Set (MDS) assessment completed. Resident identifier: 1.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality. Specifically, for 1 out of 38 sampled residents, medications were left unattended at a resident's bedside, consumption of those medications was not supervised by the licensed nurse administering them, and administration was not verified and completed in a timely manner. Resident identifier: 49.

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 1 out of 38 sampled residents, the resident did not have laboratory results filed in their medical record. Resident identifier: 18.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain records on each resident that were complete and accurately documented. Specifically, for 1 out of 38 sampled residents, a resident that received a narcotic did not have the narcotic signed out as administered. Resident identifier: 1.

Inspectors wroteBased on record review and interview, it was determined the facility did not ensure that 7 of 14 sampled residents were free of significant medication errors. Specifically, one resident received another resident's medications, which resulted in a hospital admission and subsequent continuous heart monitoring. Additionally, three residents did not receive medications according to physicians' orders, one received a medication for which the resident had a known allergic reaction, and two received the incorrect medications; these errors did not result in adverse outcomes. Resident Identifiers: 3, 7, 10, 11,12,13,14.

Inspectors wroteBased on interview and record review it was determined, for 1 of 14 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, an allegation of neglect was not thoroughly investigated to determine if neglect had occurred. Resident identifier: 6.

Inspectors wroteBased on interview and record review it was determined, for 1 of 14 sampled residents, that the facility did not ensure that the residents received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was manually lifted by two staff members, instead of using a Hoyer lift, which resulted in an assisted fall to the ground. Resident identifier: 4. Findings Include: 1. Resident 4 was initially admitted to the facility on [DATE] and again on 1/6/24 with diagnoses which included contracture of right hand, sarcoid myocarditis, severe protein-calorie malnutrition, patellofemoral disorders of left knee, neuromuscular dysfunction of bladder, depression, generalized anxiety disorder, unspecified convulsions, foot drop of right foot, muscle weakness, age-related osteoporosis, and repeated falls. Resident 4's Electronic Medical Records were reviewed. [...]

Inspectors wroteBased on observation and interview, it was determined, the facility failed to have no more than 14 hours between a substantial evening meal and breakfast the following day, without providing all residents with a nourishing snack served at bedtime. Specifically, the hours from dinner to breakfast the following day was 15 hours, and a nourishing snack was not available or offered to all residents. Resident identifier: 34.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the sanitation bucket in the kitchen was outside of the recommended concentration.

Inspectors wrote5. On 8/16/23 at 8:53 AM, an observation was made of Registered Nurse (RN) 2 during the morning medication pass. RN 2 was observed to drop one white tablet on the top of their medication cart. RN 2 then proceeded to pull out hemostats from their pocket, picked the tablet up, and put the tablet in the medication cup for resident administration. On 8/16/23 at 11:00 AM, an interview was conducted with RN 2. RN 2 stated that before they began their medication pass, they disinfected the top of their medication cart, and checked the supplies inside the medication cart. RN 2 stated they were very obsessive compulsive about cleanliness and her medication cart did not get dirty unless there was a certain resident messing with the cart. RN 2 stated they also disinfected the medication cart after they were done passing medications. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, for 1 out of 35 sampled residents, a resident that was at risk for pain did not have a baseline care plan developed within 48 hours of the admission. Resident identifier: 149.

Inspectors wroteBased on observation, interview, and record the review, it was determined, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 35 sampled residents, a resident that was observed and verbally expressed their pain was not provided pain medication in a timely manner. Resident identifier: 149.

Inspectors wroteBased on interview and record review, it was determined, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 35 sampled residents, a resident's medications were not administered as ordered by the physician due to the medication not being available by the pharmacy. Resident identifier: 19.

Inspectors wroteBased on observation, interview and record review it was determined for 1 of 51 sample residents a facility staff member did not ensure a safe environment while providing care. Specifically, resident 27 rolled out of bed when a Certified Nurse Aide (CNA) was changing the resident's bedding. Resident 27 sustained a bloody nose and a hematoma to her forehead.

Inspectors wroteBased on interview and record review, the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, 2 of 51 sample residents were not provided their physician-prescribed pain medications in a timely manner. This resulted in a finding of harm for resident 411. Resident identifiers: 97 and 411.

Inspectors wroteBased on interview and record review, it was determined the facility did not ensure that each drug regimen was free from unnecessary drugs for 1 of 51 sample residents. An unnecessary drug is any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, the facility was not monitoring an anticoagulant medication. This resulted in a finding of harm for the resident. Resident identifier: 74.

Inspectors wroteBased on interview, it was determined the facility did not designate a person to serve as the director of food and nutrition services who met the following requirements no later than 1 year after November 28, 2016 for designations after November 28, 2016: a certified dietary manager; or a certified food service manager; or has a similar national certification for food service management and safety from a national certifying body; or has an associate's or higher degree in food service management or in hospitality. Specifically, the Registered Dietitian (RD) was not employed on a full-time basis and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services.

Inspectors wroteBased on observation, interview and record the review, it was determined that the facility did not have sufficient staffing to provide appropriate cares to residents. Specifically, there were multiple complaints by residents that there is not enough staffing to meet their needs. Resident identifier: 12, 14, 15, 26, 27, 43, 45, 47, 53, 55, 57, 70, 73, 75, 86, 88, 89, 93, 259 and 260.

Inspectors wroteBased on interview, observation, and record review, the facility did not provide routine and emergency drugs and biologicals to 3 of 51 sample residents. Specifically, residents were not administered pain or statin medications. Resident identifiers: 70, 97 and 411.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 10 of 51 residents that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was not 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. In addition, there were complaints in the resident council meetings regarding food quality. Resident identifiers: 10, 15, 27, 43, 55, 64, 70, 88, 92 and 104.

Inspectors wroteBased on observation, interview and record the review, it was determined that the facility did not follow infection control policies. Specifically, staff were observed not wearing appropriate Personal Protective Equipment (PPE), and uncovered food was delivered to residents.

Inspectors wroteBased on interview and record review, the facility did not Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.

Inspectors wroteBased on an observation of staff interacting with a resident, as well as staff and resident interviews, it was determined facility staff treat 2 of 51 sample residents with respect and dignity. Resident identifier 12 and 85. Findings Include: 1. Resident 12 was admitted on [DATE], with diagnoses that included, a malignant neoplasm of brain, morbid obesity, overactive bladder, major depressive disorder, recurrent insomnia, anxiety disorder, cognitive communication deficit, muscle weakness, and pain. An interview was conducted with resident 12 on 10/12/21 at 2:03 PM. Resident 12 stated, The staffing is the only thing bad I have to say about this place - and that's only because I'm not able to toilet myself without assistance. Resident 12 stated the nurse aides will tell her, One more minute. One more minute. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility did provide notice to each resident when changes in coverage were made to items and services covered by Medicare and/or by the Medicaid State plan. Specifically, the facility failed to provide a Notice to Medicare Provider Non-coverage (NOMNC) to 1 of 51 residents when changes were made to the services covered by Medicaid. Resident identifier 47. Findings Include: Resident 47 was admitted to the facility on [DATE] with diagnoses that included gout, heart failure, morbid obesity, muscle weakness, and hypertension. On 10/12/21 at 10:57 AM, an interview with resident 47 was conducted. Resident 47 stated that physical therapy had recently stopped provided services to him. Resident 47 stated that he was not sure why physical therapy staff had stopped his services. [...]

Inspectors wroteBased on observation, interview and record the review, for 2 of 51 sample residents, it was determined that the facility did not ensure that a quality assessment was completed in the appropriate time frame of at least every three months. Specifically, Minimum Data Set (MDS) assessments were not completed timely. Resident identifiers: 3 and 4.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide 2 of 51 sample residents with supportive treatment and services to maintain or improve his or her ability to carry out the activities of daily living which included bathing or showering. Specifically, residents complained they were not showered according to their shower schedules. Resident identifiers: 27 and 57.

Inspectors wroteBased on observation, interview and record the review, for 1 of 51 sample residents, it was determined that the facility did not ensure that a resident would be successful in their bowel and bladder training program. Specifically, resident needed to wait an undue amount of time when they pushed the call light for bathroom assistance. Resident identifier: 12.