Rocky Mountain Care - Cottage on Vine

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: 1. Resident 200 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, chronic kidney disease, bipolar disorder, type 2 diabetes mellitus, and morbid obesity. On 6/14/24 at 2:24 PM, an entity 358 report was received by the SSA. The report stated that on 6/13/24, during the evening shift, resident 200 alleged that a Certified Nursing Assistant (CNA) told her to go to the bathroom in your pants and that she did not have time to help the resident. The report also…

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 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. Findings included: 1. 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 2/15/2025, Resident 28 was transferred via Emergency Medical Services from the facility to the emergency room at the local hospital, where the resident was admitted . The resident returned to the facility on…

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 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. Findings included: 1. Resident 99 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, metabolic encephalon, acute kidney failure, low back pain, generalized anxiety disorder, macular degeneration, chronic pain, and urinary tract infection (UTI). On 3/3/25 at 11:46…

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 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. Resident 28 stated that she had missed scheduled medications in the past due to the facility not having the medications in stock. A review of the Medication Administration Record (MAR) for February…

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 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. Findings included: Resident 45 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, PTSD, major depressive disorder, borderline personality disorder, and generalized anxiety disorder. Resident 45's medical record was reviewed on 3/4/25 through…

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 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. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, paraplegia, neurogenic bladder, and neuromuscular dysfunction of bladder. Resident 12's medical record was reviewed on 3/3/25 through 3/6/25. A review of resident 12's progress notes revealed the following: a. On 11/4/24 at 6:43 AM, a physician progress note documented, . [resident 12] presents with a suspected urinary tract infection (UTI). She reports experiencing backache, stomachache, and headache, which she believes are typical symptoms of a UTI for her, patient is a quadriplegic and cannot feel dysuria. [Resident 12] also…

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 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. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which consisted of quadriplegia, type 2 diabetes mellitus, dysphagia, anemia, antiphospholipid syndrome, pressure ulcer of right buttocks, and hypertension. On 3/5/25, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included suicide attempt, fall on same level, morbid obesity, obstructive sleep apnea, suicidal ideations, difficulty walking, dissociative identity disorder, need for assistance with personal care, hypothyroidism, type II diabetes mellitus, hypertension, atrial fibrillation, bipolar disorder, post traumatic stress disorder, chronic…

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 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. Findings include: Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included substance use disorder, schizoaffective disorder, anxiety, and a traumatic brain injury. Resident 3 was admitted on [DATE] with diagnoses that included dementia and encephalopathy. Resident 1's and resident 3's medical records were reviewed on 5/14/24. Resident 1's quarterly Minimum Data Set (MDS) assessment documented that resident 1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Resident 3's quarterly MDS assessment documented that resident 3 had a BIMS score of 4, which indicated severe cognitive impairment.…

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 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. Findings include: Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included suicide attempt, fall on same level, morbid obesity, obstructive sleep apnea, suicidal ideations, difficulty walking, dissociative identity disorder, need for assistance with personal care, hypothyroidism, type II diabetes mellitus, hypertension, atrial fibrillation, bipolar disorder, post traumatic stress disorder, chronic kidney disease stage 3 and panic disorder. Resident 10's medical record was reviewed on 5/14/24. Progress notes were reviewed and revealed the following: 1. On 3/21/24 at 11:51 PM, Resident on alert charting for recent fall on 3/21. Neuros started, frequent checks, call light…

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 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. Findings include: Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included suicide attempt, fall on same level, morbid obesity, obstructive sleep apnea, suicidal ideations, difficulty walking, dissociative identity disorder, need for assistance with personal care, hypothyroidism, type II diabetes mellitus, hypertension, atrial fibrillation, bipolar disorder, post traumatic stress disorder, chronic kidney disease stage 3 and panic disorder. Resident 10's medical record was reviewed on 5/14/24. A complaint form 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included suicide attempt, fall on same level, morbid obesity, obstructive sleep apnea, suicidal ideations, difficulty walking, dissociative identity disorder, need for assistance with personal care, hypothyroidism, type II diabetes mellitus, hypertension, atrial fibrillation, bipolar disorder, post traumatic stress disorder, chronic kidney disease stage 3 and panic disorder. Resident 10's medical record was reviewed on 5/14/24. The progress note section of the…

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 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. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, glaucoma, legal blindness, gastro-esophageal reflux disease, osteoarthritis, dysphagia and muscle weakness. Resident 4's medical record was reviewed on 11/8/23. The nursing progress notes dated 10/15/23 at 12:24 AM revealed, At approximately 1830 (6:30 PM) hours patients roommate came out to nurses station…

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 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. Findings included: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, morbid obesity, type II diabetes mellitus, hypothyroidism, edema, urinary tract infection, cellulitis, insomnia, pain, major depressive disorder, sick sinus syndrome, obstructive sleep apnea, gout, atrial fibrillation, atypical femoral fracture, chronic respiratory failure, and gastro-esophageal reflux disease. On 11/8/23 at 10:17 AM, an interview was conducted with the resident 3. Resident 3 stated that she was not able to stand very long in the sit to stand mechanical…

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 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. Findings included: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, morbid obesity, type 2 diabetes mellitus, hypothyroidism, edema, urinary tract infection, cellulitis, insomnia, pain, major depressive disorder, sick sinus syndrome, obstructive sleep apnea, gout, atrial fibrillation, atypical femoral fracture, chronic respiratory failure, and gastro-esophageal reflux disease. On 11/8/23 at 10:17 AM, an interview was conducted with the resident 3. Resident 3 stated that she was not able to…

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 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. Findings included: 1. On 11/9/23 at 9:46 AM, an observation was made of the 100-hallway medication cart with Licensed Practical Nurse (LPN) 1, the following medications were located inside: a. A medication card which held Oxycodone 5 mg (milligram) had the back of pocket number 25 taped, a white tablet observed to be in pocket number 25. b. A medication card which held Lacosamide 200 mg had the back of pocket number 30 taped, there was no medication observed in the pocket. 2. On 11/9/23 at 10:00 AM, an observation was made of the 300-hallway medication cart with LPN 2, the following medications were located inside: c. A medication card which held Tramadol 50 mg had the back of pocket number 14 taped, there was no medication observed in the pocket. d. A medication…

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 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. Findings included: Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, type II diabetes, edema, pressure ulcer of right buttock, muscle weakness, neuromuscular dysfunction of bladder, retention of urine and insomnia. Resident 8's medical record was reviewed on 11/8/23. Exhibit 358 facility entity report documented that on 9/27/23 at 12:00 AM, the Resident [8] alleged that he refused to have his…

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 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. Findings included: Resident 14 was admitted to the facility on [DATE] with diagnoses that included Spondylosis with radiculopathy, spinal stenosis, muscle weakness, history of falling, and diabetes with neuropathy. On 11/7/23 at 10:10 AM, an interview was conducted with resident 14 who stated that the toilet in his bathroom was unsafe and that he had almost injured himself several times. Resident 14 stated he had requested that the toilet be fixed several times. Resident 14 stated he did not know who the maintenance manager was. On 11/7/23 at 10:19 AM, an observation was made of resident 14's toilet. The bolts that secured the toilet seat to the toilet were found to be loose and the toilet seat 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident 6 was admitted to the facility on [DATE] with diagnoses which included epilepsy, fracture of right humerus, intellectual disabilities, Schizoaffective disorder, anxiety disorder, dorsalgia, visual hallucinations, and pain. On [DATE], resident 6's Annual Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 9/15, which would indicate a moderate cognitive impairment. The assessment documented that resident 6 required a one-person supervision with bed mobility, transfer, ambulation, dressing; a one-person limited assist for toilet use and personal hygiene; and partial or moderate assistance for shower/bathing. Resident 7 was admitted to the facility on…

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 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. Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included malignant of right breast, polycythemia vera, hyponatremia and hypo-osmolality, alcohol dependence, major depressive disorder, generalized anxiety disorder, shortness or breath and adult failure to thrive. Resident 10's medical record was reviewed on [DATE]. The exhibit 358 initial entity report documented on [DATE] at 11:00 AM, Alleged perpetrator was acting out of the norm [normal] and showing suspicions of being under the influence. Complied with a drug screen on 9/18. On 9/19 nurse approached DON [Director of Nursing] of potential discrepancy in NARC…

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 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. Findings included: Resident 6 was admitted to the facility on [DATE] with diagnoses which included epilepsy, fracture of right humerus, intellectual disabilities, Schizoaffective disorder, anxiety disorder, dorsalgia, visual hallucinations, and pain. On 11/7/23 through 11/8/23, resident 6's medical records were reviewed. On 12/15/22, resident 6's medical records documented that the pneumococcal vaccine was not administered due to…

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 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. Findings include: 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. On 7/27/23 at 5:41 PM, the facility reported to the State Agency (SA) that resident 6 had eloped from the building. The report stated that at 3:39, a Certified Nursing Assistant (CNA) was unable to find resident 6 while trying to follow-up with him about a missing item. The report stated that the CNA requested assistance from other employees to find resident 6. On…

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 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. Findings include: On 7/27/23 at 5:41 PM, the facility reported to the State Agency (SA) that resident 6 had eloped from the building. The report stated that at 3:39, a Certified Nursing Assistant (CNA) was unable to find resident 6 while trying to follow-up with him about a missing item. The report stated that the CNA requested assistance from other employees to find resident 6. Resident 6's medical records were reviewed. A review of resident 6's admission Minimum Data Set (MDS) dated [DATE] revealed that resident 6 scored a 6 on the Brief Interview for Mental Status (BIMS) indicating cognitive…

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, 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. Findings included: Resident 24 was admitted to the facility on [DATE] with diagnoses which included posterior reversible encephalopathy syndrome, epilepsy, dependence on supplemental oxygen, difficulty in walking, lack of coordination, muscle weakness, iron deficiency, morbid obesity, dysphagia, anxiety disorder, nausea, pressure ulcer, muscle wasting and atrophy, depression, type 2 diabetes mellitus, systolic heart failure, pain, hypokalemia, major depressive disorder, and long term use of anticoagulants. On 6/12/23 at 12:26 PM, an interview with resident 24 was conducted. Resident 24 stated that she was concerned that her bed…

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 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. Findings included: 1. Resident 11 was initially admitted to the facility on [DATE] and again on 12/2/20 with medical diagnoses which included acute chronic diastolic heart failure, obesity, vitamin deficiency, type 2 diabetes mellitus, muscle weakness, hypothyroidism, edema, hyperuricemia, cystitis, urinary tract infection (UTI), cellulitis, abdominal pain, dizziness, insomnia, hypokalemia, pain, acute recurrent sinusitis, personal history of UTIs, neuralgia, morbid obesity, major depressive disorder, sleep apnea, pure hypercholesterolemia, constipation, pain, erythematous, hypomagnesemia, gout, muscle weakness, hypokalemia,…

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 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. Findings included: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses the included, but were not limited to, posterior reversible encephalopathy syndrome, epilepsy, chronic systolic congestive heart failure, depression, type 2 diabetes…

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, 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. Findings included: MISSING ITEMS: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic kidney disease, dementia without behavioral disturbance, type 2 diabetes mellitus without complications, morbid obesity, major depressive disorder, muscle weakness, repeated falls, pain, generalized anxiety disorder, and osteoarthritis. On 6/7/22 at 10:15 AM, an interview was conducted with resident 16. 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 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. Findings include 1. On 6/6/22 at 11:30 AM, an interview with resident 17 was conducted. Resident 17 stated she was sick of having chicken day after day. Resident 17 stated that the kitchen would sometimes run out of alternative meals. 2. On 6/7/22 at 10:40 AM, an interview with resident 35 was conducted. Resident 35 stated that the vegetables were often overcooked and mushy. Resident 35 stated that the staff in the kitchen did not always follow the residents' preferences. 3. On 6/6/22 at 11:00 AM an interview with resident 10 was conducted. Resident 10 stated that the food was not good. Resident 10…

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, 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. Findings include: 1. Resident 248 was admitted to the facility on [DATE] with diagnoses which included unspecified cirrhosis of liver, malignant ascites, liver failure, metabolic encephalopathy, and history of hepatitis B and C infections. On 6/6/22 at 11:09 AM, an observation was made of Registered Nurse (RN) 4. RN 4 was observed to walk out of resident 248's room into the hallway and proceeded outside with a drainage bag containing…

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 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. Finding include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, Alzheimer's disease, adult failure to thrive and anxiety disorder. Resident 29 speaks Malayalam. On 6/8/22 at approximately 12:40 PM, an observation was made of resident 29. Resident 29 was observed to be sitting in the dining room for lunch time. A staff member was observed to be next to resident 29, providing assistance to resident 29 with eating. The staff member was heard speaking English to resident 29, however resident 29 did…

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 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. Findings include: 1. Resident 35 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis, traumatic ischemia of muscle, anxiety disorder, post-traumatic stress disorder, major depressive disorder, fibromyalgia, and cyclical vomiting syndrome. On 6/7/22 at 10:15 AM, an interview with resident 35 was conducted. Resident 35 stated that the facility was bad about getting her showers done. Resident 35 stated that this was especially true when she initially arrived at the facility. Resident 35's medical record was reviewed on 6/8/22. Resident 35's admissions Minimum Data Set (MDS) dated [DATE] was reviewed.…

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 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. Findings include: Resident 35 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis, traumatic ischemia of muscle, anxiety disorder, post-traumatic stress disorder, major depressive disorder, acute cystitis, urinary retention, fibromyalgia, hypertension, severe protein-calorie malnutrition, and acute pancreatitis. Resident 35's medical record was reviewed on 6/6/22. Resident 35's physician orders revealed that resident 35 had an order beginning on 4/16/22 to receive enoxaparin 40 mg subcutaneously every day for a diagnosis of blood clot prevention. On 5/11/22, the facility pharmacist consultant…

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 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. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses that included paraplegia, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, pulmonary embolism without acute cor pulmonale, and long term (current) use of anticoagulants and antithrombotics/antiplatelets. Resident 33's medical record was reviewed on 6/13/22. A care plan dated 9/14/20 revealed resident 33 was at risk for complications secondary to Anti-Coagulant use. Goals in place included, resident will have no unaddressed bleeding or adverse drug events through next review. An approach listed was monitor/document/report signs or symptoms of adverse side effects…

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 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. Findings include: Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, C1-C4 incomplete, type 2 diabetes mellitus without complications, edema, benign prostatic hyperplasia, autonomic neuropathy, pain, major depressive disorder, muscle weakness, and muscle spasm. On 607/22 at 9:24 AM, an interview was conducted with resident 11. Resident 11 stated that recently a Certified Nursing Assistant (CNA) from an agency was assisting him to get out of bed using a Hoyer lift. Resident 11 stated his foot got caught between the Hoyer lift and the bed. Resident 11 stated the staff thought his foot was broken, but he did not break any bones with this incident. Resident 11 stated an x-ray 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which included dementia, coronary artery disease, hypertension, depression and anemia. Resident 24's medical record 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 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. Findings include: On 6/9/22, a list of staff that were partially vaccinated, fully vaccinated and had vaccination exemptions was provided. Employee 8 and CNA 7 were documented as partially vaccinated. CNA 8, and LPN 2 were documented with medical exemptions. According to the Center for Disease Control and Prevention (CDC) the community transmission rate was high, indicating greater than 10%, for the weeks of 5/1/22, 5/8/22, 5/15/22, 5/22/22, 5/29/22, and 6/5/22. https://covid.cdc.gov/covid-data-tracker/#county-view|Utah|49035|Risk|community_transmission_level. The work…

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 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. Findings include: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which included dementia, coronary artery disease, hypertension, depression and anemia. Resident 24's medical record 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.