Rocky Mountain Care- Clearfield

In the surveyor’s words

From the most serious findings on record at Rocky Mountain Care- Clearfield, in the surveyor’s own words.

• Actual harm, patternF684May 14, 2026

  Based on interview and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 3 out of 54 sampled residents, a resident's brief was the incorrect size and caused a wound, and another resident was unable to put his prosthetic arm on during the weekend because staff were not trained. These examples were cited at a harm level. Resident identifiers: 13, 22, and 63.Findings included:1. […]

• Actual harm, patternF725May 14, 2026

  Based on observation, interview and record review it was determined that the facility did not have 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, for 7 out of 54 sampled residents, multiple residents complained of staffing shortages, long call light response times, and delays in assistance with Activities of Daily Living (ADLs). Additionally, resident council notes documented late medication administration. Resident identifiers: 1, 7, 9, 13, 31, 73, 86, 110, 113, 127, 129, and 156.Findings included:1. On 5/5/26 at 12:55 PM, an interview was conducted with resident 86. […]

• Actual harm, isolatedF550May 14, 2026

  Based on observation, interview, and record review, the facility did not treat each resident with respect, 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, for 5 out of 54 sampled residents, staff were not provided education on how to attach a resident's prosthetic arm, residents complained of having incontinent episodes while waiting for staff to answer call lights, when the staff member tried to empty the ostomy bag it detached, resulting in scattered stool everywhere, and a resident was seated at a table that was at her chin height for breakfast. The first example was cited at harm. […]

• Actual harm, isolatedF677May 14, 2026

  Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out activities of daily living. Specifically, for 1 out of 54 sampled residents, a resident was not provided showers as scheduled. This example will be cited at a Harm level. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included morbid obesity, other lack of coordination, weakness, and other abnormalities of gait and mobility.On 5/4/26 at 2:35 PM, a concurrent observation and interview were conducted with resident 1. […]

• Actual harm, isolatedF688May 14, 2026

  Based on observation, interview, and record review the facility failed to ensure that a resident with a limited range of motion 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 54 sampled residents, a resident's range of motion decreased with restorative nursing services after the resident was discharged from physical therapy. This was cited at a harm level. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included other abnormalities of gait and mobility, other lack of coordination, and weakness.On 5/4/26 at 11:20 AM, an interview was conducted with resident 1. […]