Rocky Mountain Care - Cottage on Vine

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jun 13, 2022

  Based on interview and record review, it was determined for 7 of 39 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, one resident with severe cognitive impairment was found to be hitting and spitting on other residents. Additionally, interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. […]

• Immediate jeopardy, patternF609Jun 13, 2022

  Based on record review and interview it was determined for 7 of 39 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. […]

• Immediate jeopardy, patternF610Jun 13, 2022

  Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 7 of 39 sample residents. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to investigate abuse. […]

• Immediate jeopardy, isolatedF689Jun 13, 2022

  Based on observation, interview and record review it was determined, for 1 of 39 sample residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident with a diagnoses of dementia and [NAME] was found with hazardous liquids and foreign objects. This was found to have occurred at an Immediate Jeopardy (IJ) level. In addition, a resident sustained an injury during a transfer with a Hoyer lift. This was found to have occurred at a harm level. […]

• Actual harm, patternF880Nov 8, 2023

  Based on observation, interview and record review it was determined, for 8 out of 20 residents sampled, 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 infections, including COVID-19. Specifically, during a COVID-19 outbreak the facility did not perform contact and droplet precautions for COVID-19 positive residents; perform hand hygiene upon exit of a COVID-19 positive rooms; post notification to visitors that the facility was in a COVID-19 outbreak; utilize disposable utensils and dishware for COVID-19 positive residents; and isolate, transport, and launder COVID-19 positive residents linen's separately. […]