Rocky Mountain Care - Maple Dell

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jul 21, 2021

  Based on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically,with regard to residents who were on Transmission Based Precautions (TBP), staff were observed to not fully don gowns, wear soiled gowns throughout the facility, not wear appropriate eye protection, not clean face shields after exiting the room, not store face shields appropriately, not clean vital signs equipment between resident use, contaminate isolation carts, contaminate syringes by placing them on top of isolation carts, clean and store syringes inappropriately, not clean glucometers between residents, not perform appropriate hand hygiene, not wear masks… […]

• Actual harm, isolatedF760May 5, 2026

  Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from significant medication errors for one of 12 residents sampled for medication administration. Specifically, Resident #2 was inadvertently administered 13 medications intended for their roommate, including high-risk antihypertensives and antidiabetics, resulting in hypoglycemia, hypotension, and the need for acute hospitalization.The facility's noncompliance was determined to be Past Noncompliance. […]

• Actual harm, isolatedF690Oct 3, 2022

  Based on interview and record review it was determined, for 2 out of 34 sampled residents, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident had a urinalysis (UA) test completed with no follow up and the resident went to hospital for treatment. In addition, a resident with signs and symptoms of a urinary tract infection ([CONDITION(S)]) went to the hospital for treatment. Resident identifiers: 29 and 44. Findings included: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's medical record was on 9/28/22. […]

• Actual harm, isolatedF697Oct 3, 2022

  Based on observation, interview, and record review it was determined, for 3 out of 34 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences. Specifically, residents complained of uncontrolled pain with no interventions or physician follow up. In addition, a resident went to the hospital in pain after pain medications were adjusted. Resident identifiers: 25, 29, and 45. Findings included: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 12:32 PM, an interview was conducted with resident 29. […]

• Actual harm, isolatedF725Oct 3, 2022

  Based on observation, interview, and record review, it was determined, 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 13 out of 34 sampled residents, resident's complained of not having enough staff to meet there needs, staff complained there were not enough staff to complete their job duties, residents laboratory (lab) results were not followed up with after a urinalysis (UA) was completed, showers were not completed, residents administered their own medications because there were not enough staff, there were no grievances, residents sustained… […]