Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greeley County Hospital Ltcu during CMS and state inspections, most recent first.
Housekeeping staff sorted soiled laundry using only gloves as PPE, without gowns or other clothing barriers, as confirmed by staff interviews and facility policy. This practice created the potential for transfer of infectious material from soiled to clean laundry during sorting and folding.
Three residents who had previously received a single dose of Prevnar 13 did not have documentation showing they were offered or refused the updated CDC-recommended pneumococcal (PVC20) immunization. The facility's records and staff interviews confirmed that the required vaccinations had not been offered or documented for these individuals, despite a policy stating vaccines would be administered per CDC guidelines.
A resident with dementia, major depressive disorder, and Parkinson's disease was administered Seroquel without clear documentation of the targeted behaviors, unsuccessful nonpharmacological interventions, or a risk versus benefit analysis. Physician orders listed varying diagnoses for the antipsychotic use, and the care plan lacked specific behavioral indications, resulting in a deficiency related to unnecessary psychotropic medication use.
A resident with significant cognitive and mobility impairments, identified as high risk for falls, experienced a fall resulting in a head hematoma and hip fracture. Staff did not ensure the resident wore appropriate footwear or that the required chair alarm was in use, as outlined in the care plan. The fall occurred when the resident attempted to ambulate without assistance, and the alarm was found inactive and not positioned correctly, contributing to the incident.
The Consultant Pharmacist did not identify or address missing administration parameters for PRN opioid and diuretic medications for a resident, nor did they address an unapproved diagnosis for antipsychotic use in another resident. Orders lacked specific guidelines, and monthly medication reviews failed to recommend clarifications, despite facility policies requiring such oversight.
A resident with chronic pain and edema received PRN opioid and diuretic medications without specific physician parameters for administration. Staff relied on the resident’s requests and their own judgment to determine dosing and frequency, as the orders lacked clear instructions regarding pain levels or criteria for use, resulting in inconsistent medication administration.
A resident with multiple sclerosis and other conditions was served a hot beverage in a Styrofoam cup instead of the prescribed Kennedy cup, leading to a spill and second-degree burn. The incident occurred due to outdated COVID-19 guidelines, resulting in the use of disposable containers. The resident's limited mobility and hand contractures contributed to the accident.
The facility failed to submit accurate staffing information through the PBJ, as required by CMS, indicating no licensed nurse coverage on specific dates. However, payroll data showed that a licensed nurse was on duty 24/7. This discrepancy placed 16 residents at risk for inadequate staffing.
A facility failed to perform weekly skin assessments and follow-up documentation for a resident with a history of dermatitis, venous thrombosis, and anemia, who was at risk for skin issues. Despite the care plan requiring weekly skin inspections, the facility did not adhere to this, missing several weeks of assessments. Skin issues identified on two occasions were not followed up in a timely manner, placing the resident at risk for further complications.
A facility failed to date a vial of Fiasp insulin for a resident, risking the administration of expired or ineffective medication. An observation revealed the vial was accessed but not dated, contrary to the facility's policy requiring opened vials to be dated and discarded within 28 days. This oversight was confirmed by an administrative nurse.
Failure to Use Appropriate PPE Barriers During Soiled Laundry Sorting
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices in the laundry department. During observations and interviews, housekeeping staff reported that soiled laundry was sorted using only gloves as personal protective equipment (PPE), without the use of gowns or other clothing barriers. Staff acknowledged that this practice had been ongoing and recognized the potential for transferring infectious material from soiled to clean laundry during sorting and folding. Review of the facility's laundry procedures confirmed that the policy required only gloves when handling dirty or soiled laundry and did not address the use of gowns or aprons as additional barriers.
Failure to Offer and Document CDC-Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or document the offering of the CDC-recommended pneumococcal (PVC20) immunization to three residents. Each of these residents had documentation in their electronic health records of having previously received a single dose of Prevnar 13 on various dates, but there was no evidence that they had been offered or refused any further pneumococcal vaccinations as required by current guidelines. This lack of documentation and offering was identified through observation, interview, and record review. During an interview, an administrative nurse confirmed that the facility had been reviewing the pneumococcal immunization status of current residents but had not yet offered the updated pneumococcal vaccinations. The facility's policy stated that pneumonia vaccines would be administered per CDC guidelines, but the required actions had not been completed for the affected residents at the time of the survey.
Lack of Documented Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident received antipsychotic medication only with an appropriate indication and documented physician rationale, including unsuccessful attempts at nonpharmacological interventions and a risk versus benefit analysis for continued use. The resident in question had diagnoses of dementia, major depressive disorder, and Parkinson's disease, and was assessed as having moderately impaired cognition. The care plan documented the use of Seroquel, an antipsychotic, for depression and dementia, but did not specify the targeted behaviors for which the medication was prescribed. Additionally, the care plan directed staff to monitor for side effects and effectiveness, but lacked documentation of the specific behaviors being targeted by the medication. Physician orders for the antipsychotic medication listed varying diagnoses over time, including dementia with behaviors, major depressive disorder, and anxiety, without clear documentation supporting the indication for use. The facility's policy required clear and accurate physician orders, including diagnosis or indication for use, and periodic reassessment of the medication's effectiveness. However, the records did not show evidence of unsuccessful nonpharmacological interventions or a documented risk versus benefit analysis for the continued use of the antipsychotic medication, leading to the deficiency.
Failure to Implement Fall Prevention Interventions Results in Resident Injury
Penalty
Summary
Staff failed to implement fall prevention interventions for a resident with multiple high-risk factors, including atrial fibrillation, dementia, major depressive disorder, Parkinson's disease, and a history of falls. The resident required substantial to maximal staff assistance for transfers and mobility, used a walker and wheelchair, and was assessed as a high fall risk. The care plan specified the use of a chair sensor alarm to notify staff when the resident attempted to get up unassisted, and staff were instructed to ensure the alarm was moved between seating surfaces and was functioning when in use. The care plan also required staff to ensure the resident wore appropriate footwear and that the environment was free of hazards. On the day of the incident, the resident was found on the floor in front of the bathroom, alert but holding her head and complaining of pain. She was wearing regular socks, with her shoes left by her recliner, and her call light was attached to the recliner, not within her reach. The chair sensor alarm, which was supposed to be in use, was found at the foot of the bed and was not active at the time of the fall. There were no environmental hazards identified in the room. The resident sustained a head hematoma and was later diagnosed with a fractured hip, requiring hospitalization and surgery. The facility's investigation could not determine the exact cause of the fall, as it was unwitnessed, but identified contributing factors including the resident ambulating without non-skid footwear and the absence of an active chair alarm. The failure to ensure the implementation of these fall prevention interventions, as outlined in the resident's care plan, directly led to the resident's fall and subsequent injuries.
Consultant Pharmacist Failed to Identify Missing PRN Parameters and Unapproved Antipsychotic Diagnosis
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and addressed the lack of specific parameters for the use of as-needed (PRN) opioid and diuretic medications for one resident, and failed to address an unapproved diagnosis for the use of an antipsychotic medication for another resident. For the first resident, the medical record showed multiple diagnoses including chronic pain, polyneuropathy, and major depressive disorder. The resident received PRN oxycodone and bumetanide, but the physician's orders lacked specific parameters for administration, such as pain level or type, and guidelines for edema. The Medication Administration Records indicated frequent administration of these medications, and both nursing staff and administrative staff confirmed that the orders lacked necessary parameters. The monthly medication regimen reviews conducted by the CP did not include recommendations or clarifications regarding these missing parameters. For the second resident, the medical record documented diagnoses of dementia, major depressive disorder, and Parkinson's disease. The resident received Seroquel, an antipsychotic, with the physician's order citing major depressive disorder and anxiety as the indications. However, the care plan did not specify targeted behaviors for the use of Seroquel, and the diagnosis for its use was changed by nursing staff without proper documentation or physician input. The CP did not address the appropriateness of the diagnosis for the antipsychotic during monthly reviews. Administrative staff acknowledged that the diagnosis for Seroquel was not appropriately documented and that the CP had not raised this issue. Facility policies required pharmacy services to be provided in accordance with state and federal regulations, including clear and accurate physician orders for antipsychotic medications and regular review of medication appropriateness by the CP. Despite these policies, the CP did not identify or report the lack of specific parameters for PRN medications or the inappropriate diagnosis for antipsychotic use, resulting in deficiencies in medication management and oversight.
Lack of Parameters for PRN Opioid and Diuretic Administration
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not obtaining specific parameters for as needed (PRN) administration of opioid and diuretic medications. For one resident with multiple diagnoses including chronic pain, polyneuropathy, and edema, physician orders for PRN oxycodone and bumetanide lacked clear guidelines regarding the level or type of pain, the number of tablets to administer, or specific criteria for edema. The resident’s medical record showed frequent use of PRN pain medication and diuretics, with medication administration records indicating variable dosing and frequency without documented parameters. Staff interviews confirmed that the resident often determined the dose of oxycodone to take and requested PRN bumetanide as needed, with no specific instructions from the physician regarding administration criteria. The facility’s policy required medications to be administered only as prescribed and in a safe and effective manner, but the orders for PRN medications did not provide sufficient detail to guide staff in their administration. Observations and interviews revealed that staff relied on the resident’s requests and their own judgment rather than clear physician instructions, resulting in inconsistent medication administration. The lack of specific parameters for PRN opioid and diuretic use constituted a failure to ensure the resident’s drug regimen was free from unnecessary drugs, as required by regulation.
Failure to Prevent Hot Liquid Accident
Penalty
Summary
The facility failed to ensure an environment free from accidents for a resident with multiple sclerosis, major depressive disorder, dysphagia, and weakness. The resident, who had intact cognition and required set-up assistance with eating, was assessed to be at risk for spills from hot liquids and was supposed to receive hot beverages in a lidded cup. However, during a period of isolation due to COVID-19, the resident was served a hot beverage in a Styrofoam cup instead of the prescribed Kennedy cup. The incident occurred when the resident, due to limited mobility, hand contractures, and weakness, accidentally punctured the Styrofoam cup, causing the lid to pop off and the hot liquid to spill onto her abdomen. This resulted in a second-degree burn, characterized by redness, fluid-filled blisters, and tenderness. The resident was subsequently taken to the hospital for assessment and treatment of the burn. The deficiency was attributed to the dietary staff operating under outdated COVID-19 guidelines, which led to the use of disposable containers instead of the resident's prescribed Kennedy cup. The facility's failure to adhere to the resident's care plan and hot liquid assessment resulted in the accident and subsequent injury.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2024 Quarter 1 indicated that there was no licensed nurse coverage on several specific dates. However, a review of the facility's licensed nurse payroll data for those dates revealed that a licensed nurse was indeed on duty 24 hours a day, seven days a week. This discrepancy was verified by Administrative Nurse D, who confirmed that the facility had submitted nursing hours and data that lacked the coverage of agency and hospital RN coverage. The failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing. The facility had a census of 16 residents at the time of the survey. The report highlights that the facility's submission of staffing information did not include the necessary details about the category of work for each person on direct care staff, such as whether the individual was an RN, LPN, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS. This oversight in data submission could potentially lead to misinterpretations of staffing adequacy and compliance with regulatory requirements.
Failure to Conduct Weekly Skin Assessments and Follow-Up
Penalty
Summary
The facility failed to perform weekly skin assessments and follow-up documentation for a resident, identified as R9, who was at risk for skin issues. R9's medical history included dermatitis, venous thrombosis, and anemia, and the resident was noted to be at risk for pressure ulcers. Despite these risks, the facility did not conduct weekly skin assessments as required by the resident's care plan and the facility's skin assessment policy. The care plan specified that staff should perform weekly skin inspections and report any changes, but this was not adhered to. The deficiency was highlighted by the lack of follow-up documentation for skin issues identified on two separate occasions. On one occasion, an open wound was noted on R9's lower left leg, but no follow-up assessment was documented until three and a half weeks later. Similarly, another skin issue was identified on R9's toe, with no follow-up assessment for over two weeks. The facility's failure to document and follow up on these skin issues placed R9 at risk for further skin complications. This was confirmed by an administrative nurse who acknowledged the lack of documentation and follow-up.
Failure to Date Insulin Vial
Penalty
Summary
The facility failed to properly label and date a vial of insulin for a resident, identified as R15, which could lead to the administration of expired or ineffective medication. During an observation in the medication storage room, a vial of Fiasp insulin was found to have been accessed but not dated. This oversight was confirmed by Administrative Nurse D, who acknowledged that the vial should have been dated upon opening. The facility's policy mandates that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. The failure to date the insulin vial placed the resident at risk of receiving ineffective insulin.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tribune
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wichita County Health Center Ltcu | 23.3 mi | ★★★★★ | 0 | 0 |
| Holly Care Center | 34.6 mi | ★★★★★ | 0 | 0 |
| Cheyenne Manor | 38.5 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.