Deficiency Records for Rocky Mountain Care - Willow Springs
Updated as of March 01, 2024
A list of the most recent deficiencies for Rocky Mountain Care - Willow Springs. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-08-21 | 2023-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-21 | 2023-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-21 | 2023-10-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-16 | 2023-10-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-21 | 2023-10-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-21 | 2023-10-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-21 | 2023-09-19 | N |
| Meet other general requirements. | Fire Safety | 2023-08-16 | 2023-09-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-16 | 2023-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-16 | 2023-09-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-16 | 2023-09-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-16 | 2023-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-16 | 2023-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-16 | 2023-09-01 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-02-02 | 2023-03-31 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-10-03 | 2022-11-16 | Y |
| Meet other general requirements. | Fire Safety | 2021-10-14 | 2021-12-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-18 | 2021-12-01 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-18 | 2021-12-01 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-18 | 2021-12-01 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-10-18 | 2021-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-18 | 2021-12-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-18 | 2021-12-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-18 | 2021-12-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-18 | 2021-12-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-18 | 2021-12-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-18 | 2021-12-01 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-18 | 2021-12-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-18 | 2021-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-18 | 2021-12-01 | Y |
| Report COVID19 data to residents and families. | Health | 2021-10-18 | 2021-12-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-14 | 2021-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-14 | 2021-12-01 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2021-10-14 | 2021-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-14 | 2021-11-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-20 | 2019-10-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-20 | 2019-10-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-20 | 2019-10-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-20 | 2019-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-20 | 2019-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-20 | 2019-10-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-20 | 2019-10-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-08-15 | 2019-10-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-15 | 2019-10-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-15 | 2019-10-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-15 | 2019-10-15 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-08-15 | 2019-10-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-15 | 2019-10-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-15 | 2019-10-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-15 | 2019-10-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-15 | 2019-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-10-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-08-15 | 2019-10-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-15 | 2019-10-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-15 | 2019-10-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-08-15 | 2019-10-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-15 | 2019-10-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-15 | 2019-10-15 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2019-08-15 | 2019-10-15 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2019-08-15 | 2019-10-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-15 | 2019-10-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-15 | 2019-10-15 | N |
