Rocky Mountain Care - The Lodge

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 29, 2024

  Based on observations, interviews, record review, and facility document and policy review, the facility failed to provide supervision to prevent accidents related to elopement for 2 (Resident #59 and Resident #38) of 3 residents reviewed for elopement. Specifically, Resident #59 eloped from the facility on 02/24/2024 and was pushing their wheelchair when it was hit by a car. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 02/24/2024 at approximately 8:00 PM when Resident #59 eloped from the facility. […]

• Actual harm, isolatedF684Jun 4, 2026

  Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for 4 of 36 sampled residents, a resident's skin condition was not evaluated and treated, a resident had wound care provided without orders, a resident was hospitalized and no documentation was found of the resident's change in condition, and a resident expired at the facility and no documentation could be found of the resident's change in condition. Resident identifiers: 9, 59, 61, and 62.Findings included:1. […]

• Actual harm, isolatedF692Jun 4, 2026

  Based on observation, interview, and record review, for 2 of 36 sampled residents, the facility did not provide each resident assisted nutrition to maintain acceptable parameters of nutritional status. In addition, a resident was not offered a therapeutic diet when there was a nutritional problem. Specifically, a resident who was provided a tube feeding lost a significant amount of weight when the tube feeding was discontinued for 5 days and her oral intake was not meeting her nutritional needs. This example will be cited as a harm. In addition, a resident with a high potassium was not provided low potassium foods when the dialysis center ordered it. Resident identifiers: 6 and 13. Findings included:1. […]

• Actual harm, isolatedF697Jan 13, 2022

  Based on observation, interview, and record the review it was determined the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 30 sampled residents, a resident that had a fall and complained of pain was not provided pain medication for 11 days. Resident identifier: 51. Findings included: Resident 51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 51's medical record was reviewed on 1/11/22. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine temperatures were below the required manufacture temperatures for sanitizing dishes. Findings included:On 6/1/26 at 9:45 AM, an observation was made of the dishmachine. The following temperatures were observed: [Note: All temperatures were in degrees Fahernheit.] Wash was 160 and rinse was 150 for 3 loads of dishes.Wash was 160, rinse was 150 and final rinse was 135. Wash was 160, rinse was 155 and final rinse was 140.Wash was 165, rinse was 155 and final rinse was 130The above cycles were observed to have cups, plates, domes, mugs and bowls. […]