Rocky Mountain Care - Willow Springs

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 17, 2025

  Based on interview and record review, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 38 sampled residents, a resident who was identified as a two-person assist for bed mobility and incontinence care sustained a fall during a one-person assist for incontinence care. Resident identifier 264. Corrective Action: On 4/8/25, resident was assessed for injury; it was determined resident needed immediate medical attention and was sent to hospital via emergency medical services (EMS). Ensure two people were in the room when moving the resident, this included rolling and Hoyer transfers. […]

• Actual harm, isolatedF760Aug 1, 2024

  Based on record review and interview, it was determined the facility did not ensure that 7 of 14 sampled residents were free of significant medication errors. Specifically, one resident received another resident's medications, which resulted in a hospital admission and subsequent continuous heart monitoring. Additionally, three residents did not receive medications according to physicians' orders, one received a medication for which the resident had a known allergic reaction, and two received the incorrect medications; these errors did not result in adverse outcomes. Resident Identifiers: 3, 7, 10, 11,12,13,14. Findings include: 1. […]

• Actual harm, isolatedF691Oct 3, 2022

  Based on observation, interview, and record review it was determined for 1 of 6 sample residents that the facility did not ensure that a resident who required colostomy services, received care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident with a suprapubic urostomy pulled out his suprapubic catheter and did not have it replaced before it closed, for which the resident resident required urgent replacement outside of the facility. The findings for this deficiency were determined to have occurred at a harm level. Resident identifier: 6. […]

• Actual harm, isolatedF689Oct 18, 2021

  Based on observation, interview and record review it was determined for 1 of 51 sample residents a facility staff member did not ensure a safe environment while providing care. Specifically, resident 27 rolled out of bed when a Certified Nurse Aide (CNA) was changing the resident's bedding. Resident 27 sustained a bloody nose and a hematoma to her forehead. Findings include: Resident 27 was admitted to the facility on [DATE] with diagnoses that included; [CONDITION(S)], hypertension, type 2 diabetes mellitus, [CONDITION(S)], anxiety disorder, depression, and [CONDITION(S)]. On 10/12/21, an interview was conducted with resident 27. Resident 27 stated she had experienced a fall when a CNA was changing her bedding following an incontinence brief change. […]

• Actual harm, isolatedF697Oct 18, 2021

  Based on interview and record review, the facility did not ensure that pain management is 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, 2 of 51 sample residents were not provided their physician-prescribed pain medications in a timely manner. This resulted in a finding of harm for resident 411. Resident identifiers: 97 and 411. Findings include: HARM 1. Resident 411 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/21 at 1:35 PM, an interview was attempted with resident 411. Resident 411 stated that she was in pain, and was waiting for staff to bring her pain medications. […]