Rocky Mountain Care - Evanston
Inspection history, citations, penalties and survey trends for this long-term care facility in Evanston, Wyoming.
- Location
- 475 Yellow Creek Rd, Evanston, Wyoming 82930
- CMS Provider Number
- 535038
- Inspections on file
- 17
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rocky Mountain Care - Evanston during CMS and state inspections, most recent first.
Unlabeled food was found in the walk-in refrigerator, and a cook was observed using soiled gloves while leaving the tray line, touching surfaces, handling bread, and continuing meal prep without removing the gloves. The dietary manager and dietitian stated open items in the refrigerator had to be labeled and dated, and staff were expected to remove gloves and perform hand hygiene when leaving the service line and before resuming meal service.
A resident with Alzheimer's Disease, depression, anxiety, and insomnia was severely cognitively impaired and unable to participate in BIMS scoring, yet the facility did not ensure regularly scheduled care plan meetings were planned or held. The resident representative said prior meetings only occurred after prompting, the record showed IDT care planning meetings in prior quarters, and the DON and Administrator confirmed no care plan meetings had been scheduled after the last documented meeting.
Failure to provide individualized 1:1 activities for a cognitively intact resident with dementia, depression, and blindness. The resident's MDS showed preferences for reading, music, animals, news, group activities, favorite activities, fresh air, and religious practices, and the care plan included weekly 1:1 visits. However, activity records showed no evidence that 1:1 activities were offered or refused, and the AD stated the facility did not have a set 1:1 activity or document when such visits were offered.
A resident with cognitive impairment and a history of falls, who required two-person assistance for transfers, was transferred by a CNA alone, contrary to the care plan. This resulted in the resident falling, sustaining a comminuted femur fracture above a knee prosthesis, and requiring significant pain management.
A resident with moderate cognitive impairment experienced verbal abuse from a CNA, who responded to the resident's expletives with a derogatory term. The incident caused emotional distress to the resident, who felt mocked and belittled. The CNA admitted to the behavior and was terminated. The resident, who typically used foul language, was notably affected, leading to the acceptance of counseling services.
The facility did not provide written transfer notices to two residents who were hospitalized, despite issuing bed hold notices. The administrator confirmed that while discharge notices included appeal rights and Ombudsman contact information, transfer notices for hospitalizations were not issued.
A resident with major depressive disorder, anxiety disorder, and PTSD remained in the facility beyond 120 days without a required level II PASARR being completed. The initial PASRR level I indicated the need for a level II determination if the stay was extended. The facility administrator confirmed the oversight.
The facility failed to inform two residents that signing a binding arbitration agreement was not a condition for admission or continued care. The agreements did not allow residents to decline the arbitration clause while accepting other terms. Despite claims that no such agreements were signed, records showed otherwise, and the facility's lawyer acknowledged issues with older agreements.
Unlabeled Food Storage and Improper Glove Use During Meal Preparation
Penalty
Summary
Food was not stored and prepared in accordance with professional standards in the kitchen. On 4/14/26 at 6:24 AM, surveyors observed a red tub containing a thick yellow substance in the walk-in refrigerator. The bowl was not labeled or dated, and the substance appeared to have portions removed. The dietary manager and dietitian later identified the substance as potato salad and stated they were not sure when it was made. They also stated that items in the walk-in refrigerator were available for resident consumption and that all open items had to be labeled and dated. On 4/15/26 at 12:09 PM, cook #1 was observed plating meals on the tray line while wearing gloves. Without removing the gloves, the cook left the line, touched the three-compartment sink, placed a hand on top of a table, obtained a bag of bread, and returned to the tray line. The cook then opened the bread bag and used the same soiled gloves to remove two slices of bread, placed an enchilada on the bread, and gave the tray to staff in the dining room for a resident. The cook returned to the service line and continued preparing meal trays without removing the soiled gloves. The dietary manager and dietitian stated they expected staff to remove gloves and perform hand hygiene when leaving the service line and before resuming meal service.
Failure to Schedule Regular Care Plan Meetings
Penalty
Summary
The facility failed to ensure resident #3 was notified in advance and included in regularly scheduled care plan meetings for development and implementation of the person-centered plan of care. The quarterly MDS showed the resident was unable to participate in BIMS scoring because the resident was rarely or never understood and was severely impaired in daily decision making. The resident had diagnoses of Alzheimer's Disease, depression, anxiety, and insomnia. The resident representative stated the resident had two care plan meetings in the last year, but those meetings were prompted by the representative. The medical record showed interdisciplinary team care planning meetings with the resident representative invited in April 2025, July 2025, and October 2025, but there was no evidence of a care plan meeting planned or held in 2026. The DON confirmed the resident had no IDT meetings for care plan updating since October 2025 and none were scheduled, and the Administrator stated care plans had been revised quarterly with no scheduled meetings.
Failure to Provide Individualized 1:1 Activities
Penalty
Summary
The facility failed to ensure individual activities of preference were provided for one resident who was cognitively intact with a BIMS score of 15 out of 15 and diagnoses including non-Alzheimer's dementia, depression, and blindness in both eyes. The resident's MDS indicated that it was very important to have books, newspapers, and magazines to read, listen to music, be around animals, keep up with the news, do things with groups of people, do favorite activities, get fresh air when the weather was good, and participate in religious services or practices. The Recreation Therapy care plan, last revised on 12/31/26, included an intervention to provide a 1:1 visit once weekly. Observation showed the resident in the room independently listening to an audio book. The resident stated s/he did not participate in many activities because of blindness and did not have many visitors, and said staff did not come to the room for visits. Review of activity participation records for the two-month period showed no evidence the resident was offered 1:1 activities or refused them. The activity director stated the resident's family provided many activities, the resident listened to audio entertainment, and the facility only did 1:1 activities when reading mail to the resident; she also stated the facility did not have a set 1:1 activity with the resident and did not document when 1:1 activities were offered, and the facility did not have a policy related to 1:1 activities.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, Alzheimer's disease, and bipolar disorder, who required substantial to maximal assistance with all mobility activities of daily living (ADLs), was not provided a safe transfer as outlined in their care plan. The care plan specified that two staff members were required to assist with transfers due to the resident's fall history and high level of assistance needed. Despite this, a certified nursing assistant (CNA) attempted to transfer the resident alone, resulting in the resident losing balance, falling, and hitting their head. Initial nursing assessment did not reveal injury or pain, and the resident resumed normal activities. Subsequently, the resident began to complain of severe knee pain and was diagnosed with a comminuted fracture above the left knee prosthesis, which was inoperable. The resident was placed on non-weight bearing status and required increased pain management. The facility's investigation confirmed that the CNA did not follow the care plan, leading to the resident's fall and injury.
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, resulting in actual psychosocial harm. The incident involved a resident with moderate cognitive impairment and a history of cerebrovascular accident, hemiplegia or hemiparesis, and depression. During an incident, the resident used expletives towards a CNA, who responded by calling the resident a derogatory term. The resident reported feeling mocked and belittled by the CNA, which led to emotional distress. The resident's representative confirmed the resident's feelings of embarrassment and belittlement, and the resident was described as being stunned after the incident. The investigation revealed that the CNA admitted to using the derogatory term and was subsequently terminated. The resident, who often used foul language, was notably affected by this incident, as evidenced by their acceptance of counseling services afterward. The facility's administrator confirmed the resident's unusual emotional response and the initiation of counseling services. The facility's policy on abuse, neglect, and exploitation was reviewed, highlighting the requirement to prohibit and prevent such incidents.
Failure to Provide Written Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written notice of transfer to the resident and/or their representative for two residents who were hospitalized. Resident #3 was admitted to the hospital on March 30, 2024, and returned to the facility on a later date. Although the resident received a bed hold notice, there was no evidence of a written transfer notice being issued. Similarly, resident #21 was hospitalized on July 14, 2024, and returned to the facility on a later date, but also did not receive a written transfer notice, despite receiving a bed hold notice. During interviews, the facility administrator acknowledged that while written notices containing appeal rights and Ombudsman contact information were issued for discharges, they did not issue written transfer notices for hospital transfers.
Failure to Complete Level II PASARR for Resident
Penalty
Summary
The facility failed to complete a required level II PASARR for a resident who was admitted with diagnoses of major depressive disorder, anxiety disorder, and PTSD. The initial PASRR level I screening indicated that the resident had a major mental illness and was categorically appropriate for convalescent care after an acute hospital stay, not to exceed 120 days. The screening also noted that an individualized level II determination would be required on the 120th day if the resident's stay was to be extended. Despite the resident remaining in the facility beyond 120 days, there was no evidence in the medical record that the level II PASARR was completed. The facility administrator acknowledged that the level II PASARR was not conducted as required.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement explicitly stated that residents or their representatives were not required to sign the agreement as a condition of admission or to continue receiving care. This deficiency was identified for two residents who signed admission agreements that included a binding arbitration clause. The agreements did not provide an option for the residents to decline the arbitration agreement while agreeing to the rest of the admission terms. Despite the administrator's statement that no residents had signed binding arbitration agreements, medical record reviews revealed otherwise. The facility's lawyer acknowledged that older admission agreements were problematic, although the facility had revised their admission agreements in 2023 to comply with regulations related to arbitration.
Latest citations in Wyoming
A facility failed to keep residents’ personal and medical records secure and confidential. Medical record review showed hospice notes were entered directly into the EMR for three residents, and the regional clinical director stated the hospice previously used was given full access to the EMR for all residents. The Resident Rights policy stated residents have a right to secure and confidential personal and medical records.
Failure to Offer Choice of Hospice Provider: The facility did not ensure that 3 residents receiving hospice services were offered a choice of hospice provider. Medical record review showed no evidence that the residents were given provider choice, and an RCD confirmed that prior to the operator transition, hospice residents were not given a choice. The facility's Resident Rights policy states residents have the right to choose health care and providers of health care services.
Failure to Assess and Document Changes in Condition: A resident with repeated falls, hypoxia, lethargy, and later hospital transfers had multiple episodes where assessments, vital signs, or follow-up documentation were missing or delayed. Another resident with COPD and impaired gas exchange was observed in respiratory distress without oxygen and was later transferred for respiratory failure, with no transfer documentation on the progress notes. A third resident with dementia and a history of falls had incomplete post-fall assessments and was later sent to the hospital after additional falls and pain. A fourth resident with a Foley catheter had cloudy, low, and absent output, pain, and family requests for transfer; the catheter was later found to have caused traumatic injury and hematuria.
Opened medications in two medication fridges were found without required opened-on or discard dates. An Ozempic pen in one fridge and an opened Tubersol vial plus an opened Ativan oral solution in another fridge were all in use but unlabeled, and staff confirmed the missing dates. The DON stated she expected in-use multi-dose vials to have an opened-on or discard-by date, and manufacturer guidance reviewed for these medications specified discard timelines after opening.
A facility failed to ensure hospice services met professional standards for 3 sampled residents. Medical record review showed each resident was receiving hospice services, but none of the records contained a physician order for hospice referral or eval. An RCD confirmed that residents placed on hospice did not receive a physician order for eval and that the hospice used at the time had access to all resident medical records.
Infection control was not maintained during meal service and resident care. A CNA touched hair, clothing, and other surfaces while handling meal tickets, food, and drink cups without hand hygiene, including placing chips on a resident’s burger and touching cup rims. Staff also left visibly soiled linens in place for a resident with bowel incontinence, and oxygen cannulas/tubing for multiple residents were found on the floor or unlabeled, with one cannula picked up from the floor and placed on a resident.
A facility failed to ensure pneumococcal immunization status was assessed for 5 of 5 sampled residents. Medical record review showed no evidence that PCV had been assessed or offered, and the IP confirmed there was no documentation of pneumococcal vaccination status. The facility reported its immunization process tracked vaccines on admission and documented annual COVID and influenza vaccines, but the pneumococcal audit had been delayed because records could not be accessed.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
Failure to Investigate Allegation of Verbal Abuse: A volunteer reported that an activities staff member yelled at a resident during bingo and then yelled at the volunteer when she intervened. Interviews with the resident and volunteer confirmed the staff member spoke rudely and loudly to the resident, and the regional clinical director confirmed there was no evidence the verbal abuse allegation was reported or investigated.
Failure to Allow Return After Hospital Transfer: A resident was transferred to the ER for altered mental status and increased confusion, but the facility did not provide a transfer/discharge notice and did not allow the resident to return after the acute hospitalization. The DON stated the decision not to permit return was financial, while the business office manager believed it was due to insufficient staffing. The facility policy stated residents transferred to acute care will be permitted to return upon discharge, and not permitting return constitutes a discharge.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained secure and confidential. Medical record review showed that resident #26 received hospice services beginning on 1/2/26, resident #83 received hospice services beginning on 1/21/26, and resident #84 received hospice services beginning on 2/5/26, and the hospice provided documented notes directly into the electronic medical record system. During interview on 5/6/26 at 12:44 PM, the regional clinical director stated the only hospice used prior to a change in operator was given full access to the electronic medical record for all residents. Review of the facility’s Resident Rights policy stated residents have a right to privacy and confidentiality of personal and medical records and the right to secure and confidential records.
Failure to Offer Choice of Hospice Provider
Penalty
Summary
The facility failed to ensure residents' right to choose their health care providers for 3 of 12 sampled residents reviewed for hospice services. Resident #26 began receiving hospice services on 1/2/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but the medical record review showed no evidence that any of these residents were offered a choice in hospice provider. During an interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that prior to the operator transition, residents on hospice were not given a choice for hospice provider. The facility's Resident Rights policy, last revised on 6/10/25, states that the resident has the right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care.
Failure to Assess and Document Changes in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for four residents who experienced changes in condition. For resident #1, the record showed multiple episodes where the resident was found after falls, had low oxygen saturations, became lethargic, or was unresponsive, yet there was no evidence of timely assessments, vital signs, or follow-up documentation at several of those events. The record also showed a late entry note for a 3/5/26 incident was added 62 days after the event. The resident was later transferred to the hospital for respiratory failure, pneumonia, acute heart failure, dry gangrene, hyponatremia, metabolic encephalopathy, pulmonary edema, critical electrolyte abnormalities, atrial fibrillation with RVR, and acute kidney injury. For resident #69, the resident had diagnoses including chronic myeloid leukemia, CAD, seizure disorder, traumatic brain injury, and COPD, and the care plan addressed impaired gas exchange. On 5/4/26, the resident was observed sitting on the edge of the bed with a respiratory rate of 30-40 breaths per minute, grey pallor, and no oxygen in place. The resident was later sent to the hospital for respiratory failure, but the progress notes for the transfer did not show documentation on 5/5/26. A later facility note stated the resident had been found with oxygen saturation of 60% on 4 lpm NC, difficulty breathing, and lethargy, and the LPN reported she had been asked to come in on her day off to document the assessment and transfer. For resident #81, who had severe cognitive impairment, dementia, COPD, atrial fibrillation, CAD, diabetes, and a history of falls, the record showed repeated falls and incomplete assessments. After a fall on 4/20/26, the assessment section was left blank. Another note dated 4/23/26 documented pain, confusion, and unsteadiness but stated there were no safety risks. After a fall on 4/25/26, staff documented vital signs and a normal assessment but did not know whether the resident hit his/her head, and there was no evidence of follow-up assessments. After a fall on 4/30/26, the resident was found on the floor with pain, and the interdisciplinary review identified impaired cognition, weakness, and self-transfers as the root cause, with a new skin tear noted. The resident's representative reported the resident was in significant pain, not at baseline, disheveled, saturated with urine, had neck swelling, and was missing a pain patch, and stated no vital signs or assessment had been done before the resident was sent to the hospital. For resident #6, who had moderate cognitive impairment, cancer, CAD, heart failure, renal disease, dementia, and an indwelling catheter, the care plan identified UTI risk related to the Foley catheter. After a recent hospitalization for sepsis related to UTI/prostate cancer, the record showed thick cloudy catheter output, complaints of pain, and periods of no catheter output. The resident's family repeatedly requested hospital transfer, and the catheter was changed after the resident had no output since the prior shift; the catheter then drained but had bloody urine. The resident later had cloudy grayish-yellow urine, was not getting up for breakfast, and was transferred to the ED. The ER report stated the Foley had caused traumatic injury and hematuria because the balloon was inflated in the prostatic urethra, and the resident also had AKI with creatinine elevated above baseline. The DON stated she expected transfer documentation to include resident condition, vital signs, notifications, and immediate or within-24-hour documentation, and confirmed that only vital signs were completed and ongoing assessment was not completed as expected.
Medication Labeling Deficiency in Two Medication Fridges
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles because opened medications in two medication refrigerators did not have an opened-on or discard date. During observation in the Rock Creek medication fridge, an Ozempic 8 mg/3 ml pen was found with no opened-on or discard date. MA-C #1 confirmed the Ozempic pen had been opened and used the day before and that no date had been written on it. In the secure unit fridge, an opened Tubersol vial and an opened Ativan oral solution 2 mg/ml were observed without opened-on or discard dates. LPN #2 confirmed both medications were in use and that neither had the required dates. The DON stated she expected an opened-on or discard-by date to be written on in-use multi-dose vials. Manufacturer instructions reviewed for Ozempic, oral liquid Lorazepam, and Tubersol specified time limits for use after opening, and the facility policy required multi-use vials to include the date initially opened or accessed.
Missing Physician Orders for Hospice Referrals
Penalty
Summary
The facility failed to ensure hospice services met professional standards for 3 of 12 sampled residents. Medical record review showed that resident #7 began receiving hospice services on 3/31/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but none of the three records contained evidence of a physician order for a hospice referral or evaluation. During interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that residents placed on hospice did not receive a physician order for evaluation and that the hospice used at that time was given access to the medical record for all residents.
Infection Control Lapses During Dining, Linen Care, and Oxygen Equipment Handling
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for resident care and meal service. During dining room observation, a CNA touched his hair, handled resident meal tickets, and repeatedly handled resident food and drink items with exposed hands without performing hand hygiene between tasks. The CNA placed a bag of chips on top of a resident’s hamburger, touched the top bun to apply jelly, handled drink cups by the rims, and continued passing trays after touching his pants, hair, and other surfaces. The infection preventionist and DON confirmed staff were expected to perform hand hygiene after touching hair, skin, or clothing and that the CNA should not have touched resident meal items without hand hygiene. The facility also failed to manage soiled linens and oxygen equipment for residents with visible contamination or tubing on the floor. One resident had linens visibly soiled with bowel movement incontinence, yet the blanket was pulled over the sheets, the soiled linen remained visible during later observations, the resident lay on top of an oxygen cannula on the soiled sheets, and housekeeping picked up the cannula from the floor and placed it on the resident. Two other residents had nasal cannulas or oxygen tubing on the floor or unlabeled, including tubing dated 4/19/26 and tubing labeled 5/3/26 that remained on the floor during repeated observations. The IP confirmed oxygen tubing should be changed and labeled weekly and as needed or when visibly soiled, that cannulas found on the floor should not be used on residents, and that soiled linens should be changed immediately.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure residents were immunized for pneumococcal disease for 5 of 5 sampled residents (#66, #69, #1, #33, and #4) reviewed for current vaccination status. Medical record review showed no pneumococcal conjugate vaccine had been assessed or offered for these residents. The infection preventionist confirmed there was no evidence of pneumococcal vaccination status, and also stated the facility’s immunization process assessed and tracked vaccines on admission, with annual COVID and influenza vaccines offered and documented, but that the pneumococcal vaccine audit had been delayed because records could not be accessed. CDC guidance reviewed by surveyors indicated that adults age 19 years or older with unknown or no prior PCV history should receive PCV15, PCV20, or PCV21.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for resident #55. A complaint/grievance form documented that a volunteer reported activities staff member #1 yelled at resident #55 during bingo after the resident called out bingo, and the volunteer stated the staff member continued yelling at the resident and then yelled at the volunteer when she intervened. The grievance also noted that two residents reported the activities staff member yelled at them all the time and spoke to them the same way during bingo. Interviews confirmed the incident involved rude and loud comments by the activities staff member toward resident #55 during bingo, including telling the resident to stop interrupting and making a smart-ass remark. Resident #55 stated the interaction upset him/her and that the staff member was later terminated. A volunteer corroborated hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was investigated.
Failure to Allow Return After Hospital Transfer
Penalty
Summary
The facility failed to ensure resident #82 was allowed to return after an acute hospitalization. A progress note dated 3/11/26 at 8:33 PM documented that the resident was transferred to the hospital emergency room for altered mental status and increased confusion. The medical record showed no evidence that a transfer/discharge notice was provided at the time of transfer. A discharge MDS assessment showed the resident’s return to the facility was anticipated and that the discharge was unplanned, with a discharge status of Short-Term General Hospital (acute hospital, IPPS). Interviews confirmed the resident did not return to the facility after the hospital transfer. The DON stated on 5/7/26 at 9:45 AM that the decision not to allow the resident to return was financial, and also confirmed that no discharge notice was provided after transfer and that the facility did not assist in finding alternate placement. The business office manager stated on 5/7/26 at 10:54 AM that the resident was not allowed to return following the hospital transfer, although he believed the reason was insufficient staffing. The facility policy stated that residents transferred to acute care will be permitted to return upon discharge and that not permitting a resident to return following hospitalization constitutes a discharge.
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