Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Medilodge Of Wyoming during CMS and state inspections, most recent first.
Incomplete Advance Directive and CPR Consent Process: A resident admitted with encephalopathy, cognitive communication deficit, mild cognitive impairment, major depression, and anxiety signed an Advanced Directives/CPR Consent form, but the form was incomplete regarding informed consent and whether additional Advance Directive or MPOA information was desired. The SSD and DON reported only the CPR decision was obtained, the resident remained full code pending physician order, and the admission care conference did not document any discussion of Advance Directives or CPR decisions.
Physician Did Not Review Pharmacist Drug Regimen Review Recommendation: A resident with HTN and GERD was receiving famotidine 20 mg BID, and the pharmacist recommended evaluating the continued need for or reduction of the medication. The EMR contained no documentation that the physician reviewed the recommendation, and the DON confirmed it had not been reviewed.
Infection Control Lapses During Medication Administration: An RN failed to follow proper infection control practices while administering a nasal spray and insulin injection to a resident. The RN waved over an alcohol-swabbed injection site instead of allowing it to dry, then returned a nasal applicator with visible residue and an insulin pen to the med cart without cleansing them. The IP nurse stated staff were expected to follow standards of care but could not state the standards for insulin or nasal spray administration.
A resident with muscle weakness and PTSD, who was cognitively intact, experienced delays in being transferred to his preferred recliner, despite it being part of his care plan. The resident frequently had to wait for extended periods due to staff availability, causing discomfort and frustration, and reported these concerns to staff regularly.
A resident with a history of stroke and legal blindness was found with a cup of pills left on his overbed table, indicating a failure in medication administration standards. The resident was not assessed or authorized to self-administer medications, contrary to facility policy requiring observation of medication consumption. The DON confirmed the need for an assessment and order for self-administration, which were not present.
Two residents experienced deficiencies in skin assessments and documentation. One resident had a skin issue on her right breast that was not accurately documented or monitored, despite her report of needing surgery. Another resident had a dressing on his right foot that was not recorded in the facility's records, and the RN responsible failed to document or notify the physician about the new skin tear. These issues indicate a lack of proper documentation and follow-up care.
Incomplete Advance Directive and CPR Consent Process
Penalty
Summary
The facility failed to obtain informed consent and failed to offer information about formulating an Advance Directive for one resident. The resident was admitted with diagnoses including encephalopathy, cognitive communication deficit, mild cognitive impairment, major depression, and generalized anxiety disorder. On the admission date, the resident signed an Advanced Directives Acknowledgements/CPR Consent form that included sections for understanding CPR and DNR options, as well as a section asking whether the signer wanted additional information about how to formulate an Advance Directive or establish a Medical Power of Attorney, but the form was incomplete in the areas related to informed consent and interest in additional Advance Directive information. The Social Services Director reported the form was new to the admission process and that the priority was to obtain the resident’s signature to establish code status. The Director of Nursing stated she assisted with the admission and only obtained the resident’s CPR decision, and that the resident would remain full code until the physician obtained two witnesses and an order on the chart. Review of the admission care conference documentation did not include the resident and did not reflect any discussion of Advance Directives or CPR decisions. The Social Services Director also stated there was no documentation showing that the resident’s family had authority to act on the resident’s behalf if the resident later became unable to make medical decisions.
Physician Did Not Review Pharmacist Drug Regimen Review Recommendation
Penalty
Summary
The facility failed to ensure the physician reviewed monthly drug regimen review recommendations for one resident, R70, who was reviewed for unnecessary medication. R70 was admitted with diagnoses including hypertension and gastro-esophageal reflux disease (GERD). The resident was receiving famotidine 20 mg twice daily for GERD since 03/2023, and the pharmacist’s drug regimen review recommendation dated 6/14/2025 stated: "This resident is receiving famotidine 20mg BID (twice daily) for GERD since 03/2023. Please evaluate for continued need/reduction." There was no indication that the physician reviewed this recommendation. Review of R70’s physician orders on 7/14/2025 at 11:14 AM showed an active order for famotidine 20 mg by mouth twice a day. Further review of the electronic medical record found no documentation that the physician had reviewed the 6/14/2025 drug regimen review recommendation. In interview on 7/24/2025 at 12:42 PM, the DON stated that R70’s drug regimen review recommendation had not been reviewed by the physician and said she was not sure how this was missed. The facility policy required irregularities identified by the pharmacist to be sent to the attending physician, with the physician documenting review and any action taken or rationale for no change.
Infection Control Lapses During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when RN C failed to follow proper infection control practices during clinical care for Resident #69. On 7/23/25 at approximately 9:41 AM, RN C administered a prescribed nasal spray and then prepared to give the resident an insulin injection via pen in the abdomen after cleansing the area with an alcohol swab. RN C waved her hand back and forth over the swabbed area to dry it before administering the injection. The report states that WHO guidance recommends swabbing the injection site for 30 seconds and allowing the area to dry for 30 seconds, and that waving a hand over the alcohol can cause it to evaporate too quickly and may introduce new microorganisms. After the injection, RN C returned to the medication cart without cleansing the nasal applicator, which had visible residue on the tip, before placing it back in the cart. RN C also did not cleanse the insulin pen before placing it in a plastic bag without sealing the bag and returning it to the medication cart. On 7/24/25 at 8:32 AM, the Infection Prevention nurse stated that staff were expected to perform duties including medication administration, hand washing, and environmental services per standards of care, but could not state the standards regarding medication administration for insulin or nasal sprays.
Failure to Honor Resident's Choice for Recliner Transfer
Penalty
Summary
The facility failed to honor the choices and preferences of a resident, identified as Resident #40, who was cognitively intact and had a care plan that emphasized the importance of self-determination and choice. The resident, who had diagnoses including muscle weakness, PTSD, and anxiety, required assistance with activities of daily living and preferred to sit in a recliner after breakfast. Despite this preference being documented in the care plan, the resident frequently experienced delays in being transferred from his wheelchair to his recliner, causing discomfort and frustration. On multiple occasions, the resident reported having to wait for extended periods before staff could assist with the transfer, as it required two staff members and the use of a Hoyer lift. During an observation, the resident was left waiting for 40 minutes before being transferred, despite repeated instructions from a registered nurse to the staff. The resident expressed ongoing concerns about the delays to various staff members, indicating a pattern of neglect in honoring his preferences and choices as outlined in his care plan.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for one resident. The resident, a male with a history of stroke, legal blindness, repeated falls, and anxiety disorder, was observed with a cup of pills left on his overbed table. The resident reported that the nurse sometimes left his morning medications for him to take upon waking, despite not being assessed or having a physician's order to self-administer medications. The facility's policy requires observation of resident consumption of medication, which was not followed in this instance. The Director of Nursing confirmed that an assessment and order are necessary for residents to self-administer medications, which were absent in this case.
Deficient Skin Assessments and Documentation
Penalty
Summary
The facility failed to ensure accurate skin assessments and timely responses to skin changes for two residents, resulting in a deficiency. Resident #54, who was cognitively intact, had a documented skin issue on her right breast that was not accurately reflected in the facility's weekly skin assessments. Despite the resident's report of needing surgery for the skin issue, there were no monitoring or treatment orders noted in the Treatment Administration Record. The Director of Nursing was unaware of the issue until it was brought to their attention by the surveyor, indicating a lack of proper documentation and follow-up on the resident's skin condition. Resident #22, also cognitively intact, had a dressing on his right foot that was not documented in the facility's records. The weekly skin assessment did not reflect any new skin issues, and there was no documentation of the right foot wound in the progress notes or care plan. The Director of Nursing was informed of the discrepancy, and it was revealed that the Registered Nurse responsible for wound rounds had failed to notify the physician or document the new skin tear due to being overwhelmed with other tasks. These deficiencies highlight the facility's failure to maintain accurate and timely documentation of residents' skin conditions, leading to a lack of appropriate treatment and care. The absence of proper assessments and documentation for both residents indicates a systemic issue in the facility's handling of skin assessments and follow-up care, which was only addressed after the surveyor's intervention.
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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 Wyoming
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehabilitation Ce | 0.6 mi | ★★★★★ | 0 | 0 |
| Harbor Post Acute Center | 2.6 mi | ★★★★★ | 11 | 0 |
| Optalis Health & Rehabilitation Of Wyoming | 3.8 mi | ★★★★★ | 41 | 0 |
| Covenant Village Of The Great Lakes | 5.4 mi | ★★★★★ | 5 | 0 |
| The Laurels Of Hudsonville | 6.2 mi | ★★★★★ | 1 | 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.