Tobacco Root Mountains Care Center

Based on observation, interview, and record review, the facility failed to ensure safe labeling of food storage in accordance with professional standards for food service safety, placing all residents at risk for consumption of expired or contaminated food and for food-borne illness. This deficient practice increased the risk of negative outcomes for all residents receiving food services from the facility. Findings include:During an observation on 5/18/26 at 1:59 p.m., of the walk-in coolers, the following items were not labeled:- Two sandwich bags with fruit,- One gallon jug of salad dressing,- An opened bag of grapes with no opened-on date.During an interview on 5/20/26 at 2:34 p.m., staff member E stated the procedure of labeling opened containers and repackaged containers included marking containers with the name of what is in the container and the date to be used by.A review of the facility's policy titled, Food Receiving and Storage, with an origination date of 6/11/20, showed, 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to indicate a specific duration for the extended use of an as needed psychotropic medication past 14 days for 1 (#15) of 11 sampled residents. This deficient practice increased the risk of negative outcomes for residents on as needed psychotropic medications. Findings include:Review of resident #15's MAR, for May 2026, showed, lorazepam oral concentrate 2 MG/ML, give 0.25 ml by mouth every 2 hours as needed for prophylaxis related to unspecified psychosis not due to a substance or known psychological condition with a start date of 10/3/25. The order did not indicate the duration for the as needed order.Review of resident #15's GDR for lorazepam, dated 2/18/26, showed, [Status Post] major [cardiovascular accident]. [Previous] on hospice. Now palliative plan in place, decline potentially at any time. [sic]Review of resident of #15's GDR for lorazepam, dated 3/19/26, showed, Palliative care plan in place. Expected decline. Need to maintain available. [sic]Review of resident of #15's GDR for lorazepam, dated 4/16/26, showed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to protect a resident from staff to resident abuse for 1 (#5) of 10 sampled residents. Findings include:During an interview on 3/12/26 at 10:44 a.m., staff member A stated the staff were educated on abuse immediately during the investigation, which was related to a abuse allegation involving resident #5 and NF9, on 2/14/26. Staff member A stated IDT reviewed every incident and adverse events including abuse were reviewed in QAPI. The facility followed its policy in reporting and investigating abuse. NF9 was no longer employed by the facility after the investigation.During an interview on 3/12/26 at 10:57 a.m., staff member B stated she was home when she got the call from staff for an allegation of verbal abuse of resident #5 by NF9. Witness statements and the camera showed NF9 pulling the [resident #5's] walker with gestures to hurry, and the staff member directed resident #5 from the dining area to her room. Staff member B stated the provider, staffing agency, and family were notified of the alleged abuse. Staff member B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to initially report an incident of suspected resident-to-resident abuse to the State Survey Agency within the required timeframe for 2 (#s 5 and 6) of 10 sampled residents. Findings include: Review of a facility reported incident sent to the State Survey Agency, showed on 7/5/25 (a Saturday) residents #5 and #6 got into an altercation. The nurse did not immediately report the incident up the chain of command to the DON or Administrator. The delay in the nurse reporting continued the risk to the residents until the altercation was identified on 7/7/25 (a Monday) during a chart review. The facility attempted to report the initial abuse allegation on 7/7/25, but the submission was not saved. The facility did not attempt to resubmit the incident to the State Survey Agency. The facility submitted the full investigation, including the initial report, on 7/11/25. The initial report was late. During an interview on 3/12/26 at 10:44 a.m., staff member A stated the incident between residents #5 and #6 happened over the weekend and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure nurses were competent to provide pain management for hospice and end-of-life care for 2 (#s 1 and 2) of 10 sampled residents. This deficient practice resulted in unnecessary pain for residents #1 and #2. Findings include:1. During an interview on 3/31/26 at 4:10 p.m., staff member O stated she and the physician were doing walking rounds, and the physician wanted resident #1 to have PRN pain medications immediately due to signs of significant pain. Staff member O stated she notified staff member B, who then instructed the floor nurse to administer pain medication immediately. Staff member O stated the floor nurse did not administer the PRN pain medication for more than four hours after she was told to give the PRN medication. Staff member O stated the floor nurse was fearful of giving the pain medication because she had been reprimanded the prior day for giving too much PRN pain medication to a resident. During an interview on 4/1/26 at 8:03 a.m., staff member J stated she second-guessed herself about giving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prevent an incident of physical and verbal abuse for 1 (#1) of 12 sampled residents. The event was identified as past non compliance due to the facility's actions. Findings include: Review of the facility reported incident, dated 12/18/24, showed resident #1 was seated in the dayroom, with his left leg elevated in a recliner. Staff member E had moved resident #1's wheelchair due to another event in the dayroom. Resident #1 became upset, yelled for his wheelchair to be replaced next to his recliner. Staff member E aggressively replaced his wheelchair next to his recliner, hitting his left leg with the wheelchair. When staff member E left the dayroom, she yelled, Is that what you wanted. Resident #1 was notably upset, assessed for injuries, with a dime sized reddened area noted on his left lower leg. Staff member E was removed from further interactions with any of the residents, while an investigation took place. Review of staff member E's employee file, on 4/8/25, showed she was last educated on the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility staff failed to revise the care plans for 2 (#s 16 and 73) of 14 sampled residents. This deficient practice negatively affected resident #16 due to a lack of pain control in her legs, and after resident #73 was readmitted from the hospital, the staff did not have adequate directions for the provision of care and services for the resident. Findings include: During an observation on 4/8/24 at 3:23 p.m., resident #16 was sitting in her wheelchair, propelling herself down the hallway. Resident #16's shoes appeared to be tight, and her feet and legs appeared swollen. During an observation and interview on 4/9/24 at 9:24 a.m., resident #16 was sitting in a wheelchair and had propelled herself into her room. Resident #16's shoes appeared to be tight, the tops of her socks had left indentations on both her legs. Resident #16 pointed to her legs and stated, My legs are puffy all the time, and get uncomfortable from time to time. During an observation and interview on 4/10/24 at 8:40 a.m., resident #16 was sitting in her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure medications were given within the one-hour time period before or after the prescribed administration time for 1 (#4) of 14 sample residents; and failed to ensure the residents safely swallowed the medications for 2 (#s 2 and 10) of 14 sampled residents. This deficient practice may result in an increased risk for adverse effects and/or complications with choking or aspiration. Findings include: 1. During an observation on 4/9/24 at 12:27 p.m., staff member J administered the medications: baclofen, cholecalciferol, TUMS, and desvenlafaxine to resident #2. Shortly after resident #2 had the medications in his mouth, staff member J turned and walked away from the resident without ensuring he had fully swallowed the medications. Resident #2's mouth was still moving and he was still swallowing the medication. During an observation on 4/9/24 at 12:56 p.m., staff member J administered the medications gabapentin and keflex to resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed maintain a system to ensure cloth recliners in the resident dayroom were monitored for necessary cleaning for infection control prevention. This deficient practice had the potential to affect all residents who utilized the dayroom, and used the recliners, as it increased the risk for the spread of infectious agents. Findings include: During an observation on 4/8/24 at 3:43 p.m., a strong urine smell was noted in the resident dayroom. In the dayroom eight recliners were cloth like material with a brown, cloth chair like cover placed over the original cloth recliners. Six of the recliners had residents sitting in them. During an interview on 4/8/24 at 3:44 p.m., staff member K stated she did not know when the recliners were cleaned or what the cleaning schedule was for the recliners. During an interview on 4/8/24 at 4:11 p.m., staff member O stated the chair covers are taken off and washed weekly, on night shift. Staff member O stated if the chair cover is soiled, it was taken off right away and sent to laundry,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.