Tobacco Root Mountains Care Center

In the surveyor’s words

From the most serious findings on record at Tobacco Root Mountains Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 1, 2026

  Based on observation, interview and record review, the facility staff failed to proactively identify and address the risks a heater posed to a dependent resident when the heater was next to the resident's bed, and the resident sustained second degree burns on her left calf, left toes, left heel, left foot, and the entire bottom of her left foot from the heater, for 1 (#1) of 10 sampled residents; and the facility failed to address a resident's complaints of pain over a period of time after the resident had the Heimlich maneuver provided, and it was later found the resident had lower right rib fractures, for 1 (#2) of 10 sampled residents. […]

• Actual harm, isolatedF697Apr 1, 2026

  Based on interviews and record review, the facility failed to ensure adequate pain management for 2 (#s 1 and 2) of 10 sampled residents. This deficient practice resulted in residents #1 and #2 having moderate and severe pain during the last day of life. Findings include:1. During an interview on [DATE] at 7:53 a.m., staff member N stated resident #1 was always in a lot of pain when staff did checks and changes.During an interview on [DATE] at 4:10 p.m., staff member O stated she and the physician were doing walking rounds, and the physician wanted resident #1 to have PRN pain medications immediately due to signs of significant pain. Staff member O stated she had notified staff member B, who then instructed the floor nurse to administer pain medication immediately. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe labeling of food storage in accordance with professional standards for food service safety, placing all residents at risk for consumption of expired or contaminated food and for food-borne illness. This deficient practice increased the risk of negative outcomes for all residents receiving food services from the facility. Findings include:During an observation on 5/18/26 at 1:59 p.m., of the walk-in coolers, the following items were not labeled:- Two sandwich bags with fruit,- One gallon jug of salad dressing,- An opened bag of grapes with no opened-on date.During an interview on 5/20/26 at 2:34 p.m., staff member E stated the procedure of labeling opened containers and repackaged containers included… […]

• No harm, potential for more than minimal, widespreadF880Mar 16, 2023

  Based on observation, interview, and record review, three staff members (E, F, and G) failed to perform hand hygiene during meal service or when moving from dirty to clean linen tasks; and, the facility failed to provide hand hygiene education to 1 new staff member (G). Findings include: 1. During an observation and interview on 3/13/23 at 6:09 p.m., staff member E pushed a resident in a wheelchair to the dining room. Staff member E walked back to the meal cart and passed a resident meal tray without performing hand hygiene. Staff member E stated she should have used hand sanitizer before passing the meal tray. During an observation and interview on 3/13/23 at 6:20 p.m., staff member F, was passing meal trays from the kitchen to the dining room. Staff member F was not wearing gloves. […]

• No harm, potential for more than minimal, isolatedF605May 21, 2026

  Based on interview and record review, the facility failed to indicate a specific duration for the extended use of an as needed psychotropic medication past 14 days for 1 (#15) of 11 sampled residents. This deficient practice increased the risk of negative outcomes for residents on as needed psychotropic medications. Findings include:Review of resident #15's MAR, for May 2026, showed, lorazepam oral concentrate 2 MG/ML, give 0.25 ml by mouth every 2 hours as needed for prophylaxis related to unspecified psychosis not due to a substance or known psychological condition with a start date of 10/3/25. The order did not indicate the duration for the as needed order.Review of resident #15's GDR for lorazepam, dated 2/18/26, showed, [Status Post] major [cardiovascular accident]. […]