Rocky Mountain Care - Hunter Hollow

In the surveyor’s words

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

• Immediate jeopardy, patternF600Oct 26, 2023

  Based on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a resident was sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access and abuse of the resident by the alleged perpetrator. This requirement was determine to be out of compliance at the severity level of immediate jeopardy. Due to the ongoing access to resident 1, by the alleged perpetrator, the scope of the noncompliance is determined to be a pattern. Resident identifier: 1. […]

• Immediate jeopardy, patternF610Oct 26, 2023

  Based on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility failed to protect residents form abuse. Specifically, a staff member had an allegation of sexual abuse toward resident 1 that was not thoroughly investigated in July 2022. An additional allegation of sexual abuse of resident 1 was made against the same staff member in September 2023 that substantiated abuse. Additionally, the facility had prior knowledge of the alleged perpetrators behaviors and the facility failed to provide protection for the resident thereby allowing ongoing access to the resident by the alleged perpetrator. This was found to have occurred at an immediate jeopardy (IJ) level. Resident identifier: 1. […]

• Immediate jeopardy, isolatedF609Oct 26, 2023

  Based on confidential and non-confidential interviews with administrative staff, therapy staff, licensed and unlicensed nursing staff, and record review, it was determined, for 1 of 9 sampled residents, the facility failed to ensure that all suspected or alleged violations involving abuse were reported immediately to the administrator and other officials in accordance with State law through established procedures. Specifically, when interviewed by surveyors, multiple staff reported observing Certified Occupational Therapy Assistant (COTA) 1 interacting with resident 1 in a suspicious manner and did not report their concerns, thereby, allowing COTA 1 ongoing access to resident 1. […]

• Actual harm, isolatedF689Dec 22, 2025

  Based on interview and record review it was determined, for 1 of 11 sampled residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident was not provided two person assistance during a brief change, which led to a fall and subsequent fractures. This resulted in a finding of harm for resident 5. Resident identifiers: 5. Findings included: Resident 5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included multiple sclerosis, wedge compression fracture of third lumbar vertebra, paraplegia, and neuromuscular dysfunction of bladder. Resident 5's medical record was reviewed on 12/22/25. […]

• Actual harm, isolatedF689Nov 8, 2023

  Based on observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 3 sampled residents, a resident that was a quadriplegic received second degree burns on his body after being served hot water by a Certified Nursing Assistant (CNA) and the resident was not supervised while drinking the hot water. […]