Rocky Mountain Care - Evanston

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 19, 2025

  Based on medical record review, review of the facility investigation report, and staff interview, the facility failed to ensure a safe transfer was provided for 1 of 7 sample residents (#1) reviewed for falls. This failure resulted in actual harm to resident #1 who was unable to keep his/her balance during a transfer. The resident suffered a comminuted [bone breaks in 3 or more places usually occurring after a forceful event] fracture involving the distal femoral diametaphysis above the femoral component of the left knee prosthesis. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 3/7/25. The findings were: 1. […]

• Actual harm, isolatedF600Sep 18, 2024

  Based on medical record review, resident and staff interview, facility incident review, and policy and procedure review, the facility failed to protect the residents' right to be free from verbal abuse by a staff member for 1 of 6 sample residents (#4). This failure resulted in actual psychosocial harm to resident #4. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/5/24. 1. Review of the quarterly Minimum Data Set assessment dated [DATE] showed resident #4 had a brief interview for mental status score of 9 out 15, which indicated moderate cognitive impairment, and diagnoses which included cerebrovascular accident, hemiplegia or hemiparesis, and depression. […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2026

  Based on observation, staff interview, review of the 2022 Food Code, and policy and procedure review, the facility failed to store and prepare food in accordance with professional standards related to labeling stored food items and hand hygiene/gloving in 1 of 1 food preparation areas (kitchen). The census was 47. The findings were: 1. Observation on 4/14/26 at 6:24 AM showed a red tub with thick, yellow substance in the walk-in refrigerator. The bowl was not labeled or dated and the substance appeared to have portions removed. 2. Observation on 4/15/26 at 12:09 PM showed cook #1 was plating meals on the tray line while wearing gloves. […]

• No harm, potential for more than minimal, widespreadF812May 19, 2022

  Based on observation, staff interview, and review of the US Food Code, the facility failed to ensure the food storage equipment was maintained in a clean and sanitary manner in 1 of 1 kitchens. The census was 44. The findings were: 1. Observations on 5/16/22 at 4:39 PM and 5/18/22 at 11:33 AM showed the following concerns with equipment: a. The ice machine had a buildup of a pink and brown discoloration on the interior part, located above the ice in the storage bin. b. The walk-in-cooler walls, ceiling, and fan covers were soiled with dark colored dust and grime. 2. Interview with the certified dietary manager (CDM) on 5/18/22 at 11:40 AM revealed the maintenance director conducted the sanitation for the ice machine. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2021

  Based on observation, staff interview, and policy and procedure review, the facility failed to ensure food was served in sanitary conditions during 1 of 2 meal observations. The census was 44. The findings were: 1. Observation on 5/12/21 at 11:32 AM showed dietary aide #1 opened the ice machine lid with gloved hands. The dietary aid grabbed a plastic cup, while wearing the same gloves used to open the lid, scooped ice into the cup from the ice machine, and dumped the ice into separate plastic cups on a cart next to the machine. After filling all of the larger cups on the cart, the staff member grabbed two smaller cups, one in each hand, and scooped ice into the cups. The dietary aide's gloved hands contacted the ice in the machine each time he scooped ice into the cups. […]