Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Optalis Health & Rehabilitation Of Wyoming during CMS and state inspections, most recent first.
A resident with dementia, chronic respiratory failure, and severe protein-calorie malnutrition did not receive timely and thorough assessment and care for a coccyx Stage 2 pressure ulcer. Required weekly skin assessments were not documented for a two-week period, the pressure ulcer was identified without notifying the legal guardian, and a specific care plan was delayed and lacked clear offloading and repositioning interventions. Recommendations for an alternating pressure mattress (APM) and offloading were not promptly implemented, the APM order was significantly delayed, and documentation indicating a turning/repositioning program and pressure-reducing devices did not result in actual interventions. The care plan was not updated when the wound was documented as resolved, and when a subsequent open coccyx area was found, there was no evidence of guardian notification or care plan revision.
A resident with Type 1 DM had a low BG identified, was told by an LPN to eat cookies, and was left without a timely BG recheck or documented ongoing assessment, contrary to the facility’s hypoglycemia policy. Later, the resident was found unresponsive with critically low BG and low O2 saturation, with no documentation that ordered glucagon or supplemental O2 were provided before EMS arrival, despite existing hypoglycemia treatment orders. Two additional residents with Type 2 DM had orders for nightly Lantus with parameters to hold if BG was below a specified level, yet BG checks were either not ordered routinely or not performed and documented on multiple days, while Lantus was still administered without recorded BG values or documented refusals.
A resident with a chronic Foley catheter had penile pain, cloudy urine, and drainage around the catheter, and an NP ordered a UA with C&S for suspected UTI. Nursing did not collect the specimen in a timely manner, the C&S was completed incorrectly, and the NP was not notified that the test had not been completed. The resident later developed flank pain and penile discharge and was sent to the ER, where a UTI was diagnosed and an antibiotic was prescribed.
Falls were not prevented for two residents when staff failed to follow care plans and post-fall assessment procedures, resulting in femur fractures. A CNA did not use the required 2-person assist for bed mobility, and an LPN moved another resident back to bed before a full assessment after an unwitnessed fall. The facility also left hazardous items unsecured in a salon and in a resident’s room, including aerosol cleaner and wound-cleaning products.
Surveyors identified multiple food service and sanitation failures, including lack of hand towels at the only kitchen handwashing sink, a leaking dining room hand sink, and a non-operational cookline hood with filters removed for several days. Resident food in the pantry refrigerator was held beyond the facility’s stated 3-day limit for TCS items, and an expired therapeutic nutrition supplement product was stored with other supplements. Kitchen staff were observed handling clean dishes and resuming food preparation after other tasks or leaving the kitchen without required handwashing, and changing gloves without washing hands. The dish machine’s sanitizing rinse did not reach required temperatures for hot water sanitization, failing to achieve the minimum plate surface temperature needed for effective sanitization.
Failure to prevent and manage pressure injuries: The facility did not follow standards of practice or its own policy for two residents with skin breakdown. One resident had a coccyx dressing with multiple dates written on it, and the DON believed the dressing had been altered so it would not need to be changed. Another resident, with stroke, cerebral palsy, and weight loss, was identified as high/moderate risk for pressure injury but was repeatedly observed without adequate offloading or repositioning support, had overdue skin checks, lacked a timely comprehensive wound assessment, missed ordered dressing changes, and had no updated care plan for the new buttock/coccyx wounds.
Fluids Placed Out of Reach for Resident With Left-Sided Paralysis: A resident with CVA-related left-sided paralysis and protein-calorie malnutrition was observed multiple times with a cup of water placed on the far-left side of the over-bed table, out of reach. She stated she could not reach the cup unless it was moved to her right side, and later activated the call light saying she was thirsty and wanted a drink but could not reach the water. Her care plan did not address her inability to reach hydration with her affected side.
A resident with a new PEG tube after a stroke was observed receiving tube feeding with the HOB at 10 degrees instead of the ordered 30 to 45 degrees. The tube feed bag lacked the start date/time and ordered rate, the flush syringe was stored improperly, and the infusion pump had no flush rate set, leaving the resident without ordered hydration for over 24 hours. The resident repeatedly said she needed a drink and was very thirsty, and an LPN said she did not double check that the hydration flush was programmed and running.
Unsafe PICC and IV therapy management was cited for two residents. One resident with a PICC for IV abx had tubing incorrectly pushed into the PICC lumen, a gauze dressing placed under the clear dressing, and no documented external catheter measurement for daily monitoring. Another resident with a PICC for IV abx had no admission documentation of catheter size, length, arm circumference, or site condition, and the ETAR lacked orders for PICC monitoring, dressing changes, infection checks, flushing, or catheter-length monitoring; the PICC was later removed without an order to stop IV abx or remove the line.
Controlled substance documentation for one medication cart was not properly maintained. The shift-to-shift inventory records showed an incorrect narcotic total carried forward across multiple counts, missing two-nurse signatures, missing end-of-shift totals, and several incorrect counts. The DON stated the documentation did not match facility policy, which required two licensed nurses to complete and sign the controlled medication count at shift exchange.
Infection control surveillance and PPE failures were identified when staff illness call-offs were documented without specific symptoms or return-to-work dates, two residents with wounds were not placed in EBP and had no EBP signage posted, and a resident with COVID-19 was observed under Special Droplet Contact Precautions while a maintenance assistant entered the room wearing only a surgical mask and left the door open.
Poor Maintenance and Cleanliness in Resident Restrooms: Surveyors observed cobwebs on vent covers in resident restrooms 11, 12, and 13, and a sagging ceiling tile partially off the grid in another resident restroom, leaving a half-inch opening. Record review showed the housekeeping process includes cleaning horizontal and vertical surfaces, dust mopping, and damp mopping, and Maintenance CC stated they were unaware of the sagging ceiling tile.
A resident with an infected hip replacement and impaired mobility reported that a CNA told her to stop using her call light, stated they would not return, then manipulated the bed controls and call light before leaving the room. The resident later awoke needing the bathroom, could not locate the call light, and subsequently had a bowel movement and urinated in bed, leaving her devastated and embarrassed. Another CNA entering after shift change found the resident upset, the bed saturated with urine and feces, and the call light wrapped with the bed remote on the floor, out of the resident’s sight and reach.
Two residents experienced significant clinical changes without provider notification. One resident with type 1 DM had multiple blood glucose readings in the 400–551 range despite an order to notify the physician for values above 200, and there was no documentation that the provider was informed. Another resident with heart disease and a pacemaker reported left-sided chest pain, received nitroglycerin, and had elevated BP and reduced O2 sats documented, but only the spouse was notified and there was no record of provider notification or entry in the provider communication log. The DON confirmed the absence of documentation in both cases.
The facility failed to prevent and monitor misappropriation of medications for two residents when an RN accepted and retained a GLP-1 (Ozempic) from the pharmacy that later could not be located, and only one LPN dispensed all PRN Norco doses to a cognitively intact resident whose pain was controlled with scheduled Tylenol and who reported not requesting the narcotic. Controlled drug records showed a missing Norco tablet that could not be accounted for, and the DON acknowledged that a single nurse exclusively dispensing a narcotic over time appeared suspicious for diversion.
A resident with dementia, anxiety, and bipolar disorder, but assessed as cognitively intact, reported that a CNA yelled at him during a dispute about a roommate’s urinal, and a CNA witness documented that the resident described the aide screaming at him and that he appeared fearful. Although the incident was reported internally and an investigation file and risk management forms were created, the resident’s EHR contained no documentation of the allegation, the verbal altercation, or any related behavioral episodes or psychosocial assessments during the period in question. The DON and NHA confirmed that such allegations were recorded only in internal incident and risk management systems, not in the resident’s medical record, resulting in incomplete and inaccurate documentation contrary to accepted professional standards.
Call Lights Left Out of Reach: A resident with stroke-related weakness and paralysis, a resident with a new PEG tube after a stroke, and another resident were observed with call lights on the floor or otherwise out of reach and out of sight. One resident stated she could not find her call light, another asked for a drink while her call light was inaccessible, and a CNA stated call lights were expected to be checked each time staff entered a room.
A resident with Bipolar II Disorder, Schizoaffective Disorder, and Schizophrenia was receiving clozapine, but the facility did not adequately monitor CBC/ANC results. The chart showed a CBC q60 days order and later references to monthly CBC monitoring, yet the order summary did not reflect monthly CBC with differential labs, and the last CBC in the record was months earlier. Psychiatry notes continued to recommend monthly CBC monitoring, while the DON stated staff were unaware of the lab testing requirements for Clozaril and the pharmacy had not recently requested CBC or ANC results.
Failure to update a resident’s care plan for Special Droplet Contact Precautions after a COVID-19 diagnosis. The resident was in isolation with posted PPE requirements, and a CNA confirmed the precautions, but the care plan still only reflected older Enhanced Barrier Precautions. The resident’s Kardex also did not show contact precautions, and the NHA stated staff were focused on orders and signage while the care plan update was overlooked.
Weights Not Obtained as Ordered for Residents With Edema and CHF: The facility failed to obtain ordered weights for three residents with edema and CHF. For one resident, weekly weights were repeatedly missed or reused; for two others, weights ordered multiple times per week were documented from prior dates instead of being newly obtained. The EMR contained no refusal documentation or rationale, and the DON confirmed the weights were not obtained as ordered.
Failure to initiate bowel protocol for constipation: A resident with dementia reported recent constipation, and record review showed a 10-day gap between documented BMs. The eMAR included a PRN order for Milk of Magnesium tied to bowel movement protocol after no BM in 72 hours, but the medication was not given until after 9 days without a BM. The RCN stated the facility does not have standing bowel protocol orders and nurses follow PRN eMAR orders.
A resident with dementia, PTSD, and chronic pain received diclofenac sodium 1% gel for both knees without a specified amount per dose or maximum daily amount in the physician order. The consultant pharmacist had recommended adding the dose quantity and maximum per joint per day, and the physician agreed, but the MAR still reflected an unspecified amount being administered. The DON acknowledged the dosing limits for Voltaren gel and the manufacturer’s instructions specify 4 grams to each knee area four times daily.
Failure to Monitor Vital Signs Before Administering BP-Dependent Medications: Two residents received BP-dependent medications without required vital sign checks or with documentation that did not match the physician orders. One resident with heart disease and HF received Midodrine despite missing pre-dose BP checks and one dose given outside ordered parameters; another resident with HTN had Lasix administered or held based on prior readings or incorrect interpretation of the hold parameter. The DON confirmed the vital signs were not obtained before each ordered administration.
The facility failed to complete and obtain ordered lab tests for residents receiving warfarin and other monitoring. A resident with heart disease and a pacemaker had repeated missing PT/INR results and no Coumadin flowsheet or anticoagulant monitoring schedule documented, even after multiple orders and an antibiotic that could affect warfarin. Another resident with AFib and a warfarin regimen also lacked the ordered INR monitoring and related documentation, and a third resident’s ordered lipid panel was not completed.
A facility failed to implement its antibiotic stewardship program for two residents reviewed for antibiotic use. One resident had cloudy, malodorous urine and mild lethargy documented, but no other UTI symptoms were recorded before Macrobid was started, and the infection control worksheet incorrectly indicated McGeer Criteria were met; several doses were then missed because the med was listed as on order even though it was available in the ADC. Another resident returned from the hospital with acute cystitis and cefuroxime, but the chart lacked documented UTI symptoms before transfer, the urine culture showed no growth, McGeer Criteria were still marked as met, and multiple cefuroxime doses were missed due to stock/pharmacy issues despite the med being available in the ADC.
Failure to Thoroughly Investigate Resident Elopement: A resident eloped from the facility and was found outside in the parking lot after a door alarm sounded. The investigation was incomplete, with inaccurate elopement risk records, missing witness statements, no documented face-to-face head count, and staff who did not follow established alarm response procedures or demonstrate adequate familiarity with elopement drills and policies.
Failure to develop and revise care plans for residents with wandering/elopement risk. Three residents had assessments, notes, or orders showing cognitive impairment and exit-seeking risk, including one resident with dementia who later eloped and was found outside in the parking lot. The facility’s records showed care plans for wandering or elopement were not in place until after the risks were identified, and leadership stated they were not aware some at-risk residents lacked care plans.
Elopement Monitoring and Response Failure: A resident with severe cognitive impairment and significant physical assistance needs eloped from the facility and was found in the parking lot after staff noticed he was missing. Surveyors found inaccurate elopement risk records, a door alarm that was not routinely tested, frequent laundry door alarms contributing to alarm fatigue, and staff who did not complete a face-to-face resident count or fully follow the elopement response process.
A resident with esophageal cancer and obstruction, receiving enteral nutrition, had their tube feeding paused and restarted by a CNA who was not trained or authorized to perform this task. Interviews with the DON and an LPN confirmed that only trained staff should handle tube feedings, but it was reported that CNAs regularly performed this action, contrary to facility policy.
The facility failed to ensure call lights were within reach for residents, compromising their ability to alert staff for assistance. A resident with dementia and mobility issues was repeatedly observed with her call light on the floor, out of reach. Another resident was unaware of the call light's location due to it being hooked through the bed frame. A CNA confirmed that staff should check call light placement, indicating a lapse in protocol adherence.
A facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident was prescribed Vimpat 50 mg twice daily, but the medication ran out on January 12, 2025, and was not available until January 16, 2025. Despite this, the Emar showed a dose was given on January 14, 2025, which was not accounted for in the Control Substance Record. The Unit Manager confirmed the medication was not available, indicating a failure to maintain accurate documentation.
The facility failed to implement Enhanced Barrier Precautions and Contact-Based Precautions for three residents, leading to infection control deficiencies. Nurses did not follow gown requirements, and Contact Precautions were delayed for two residents. Additionally, IV administration protocols were not followed for a resident, risking infection. The facility also neglected its water management plan, failing to address abnormal legionella levels, potentially affecting all residents.
A resident self-administered a nebulizer treatment without proper assessment or supervision, as the facility failed to perform necessary assessments and obtain a physician order for self-administration. The resident had diagnoses including pneumonitis and COPD, and the facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted. An LPN acknowledged the need for supervision during treatments but cited time constraints as a barrier.
A facility failed to monitor and assess the use of psychotropic medications for a resident with schizoaffective disorder, bipolar disorder, and PTSD. Despite a care plan requiring medication monitoring, there was no documentation of monitoring for side effects or effectiveness. An LPN confirmed the absence of documentation, highlighting a failure to follow the facility's policy on psychoactive drug use.
The facility failed to label and date medications, dispose of expired medications, and secure medication carts. An insulin pen was improperly stored, and several medications lacked proper labeling. Personal belongings were found in a medication room, and medication carts were left unlocked and unattended. These issues indicate deficiencies in medication management practices.
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. One resident with multiple sclerosis was unaware of the hospice staff's visit schedule, and there was no documentation of hospice participation in care conferences. Another resident with hemiplegia reported severe pain, and the RN was unaware of the hospice staff's visit schedule. The facility's social worker could not locate documentation of hospice participation in care conferences, and the last hospice records were dated over a week prior.
A resident with heart disease and hypertension was not administered the pneumococcal vaccine PCV20 upon admission, despite being due and having consented. The resident's immunization status remained pending, and the DON acknowledged the oversight, noting a lack of process to ensure timely vaccination. Facility policy required offering the vaccine upon admission unless contraindicated or previously vaccinated.
Failure to Provide Timely and Effective Pressure Ulcer Assessment and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide thorough and effective quality care to treat and prevent recurrence of a pressure sore for one resident. The resident was admitted with chronic respiratory failure, dementia, and severe protein-calorie malnutrition, and was assessed as moderately cognitively impaired with a legal guardian for medical decisions. Although an RN stated that weekly full-body skin assessments were conducted on all residents, the EMR showed no skin assessments for this resident over a two-week period. A Stage 2 pressure sore on the coccyx was first documented on 3/10/2026, but the note did not show that the legal guardian was notified. When a medical provider evaluated the resident two days later, the wound had increased in size, and recommendations were made for an alternating pressure mattress (APM) and offloading. A care plan specific to the Stage 2 pressure ulcer was not initiated until nine days after the wound was identified, and the plan lacked actionable interventions for offloading or a defined repositioning regimen. The care plan referenced a prior refusal of an APM in 2024 and a plan to reattempt, but there was no documentation of when or whether this reattempt occurred. A 3/19/2026 progress note, generated from a check-box form, indicated a turning/repositioning program and pressure-reducing devices for bed and chair, but the DON reported this documentation did not translate into implemented actions. A physician order for an APM was not entered until twelve days after the provider’s recommendation. The EMR later documented that the skin issue was resolved, but the care plan was not updated to reflect resolution, and there was no documentation of assessments or care plan changes to prevent recurrence. A subsequent total body skin evaluation documented another open, measurable coccyx area without evidence that the guardian was notified or that the care plan was revised as of 4/7/2026.
Failure to Competently Manage Hypoglycemia and Follow Insulin Parameters for Diabetic Residents
Penalty
Summary
The deficiency involves failures in recognizing and managing hypoglycemia and in administering insulin according to physician orders for three diabetic residents. One resident with Type 1 diabetes had orders for blood glucose (BG) checks before meals and at bedtime, with specific hypoglycemia treatment orders including oral glucose tablets and glucagon nasal spray. On the morning in question, an LPN obtained a BG of 69 mg/dL, documented only in a nursing note, encouraged the resident to eat cookies, and then left the room without rechecking the BG or reassessing the resident as required by the facility’s hypoglycemia policy. There was no documentation of a repeat BG within approximately 15 minutes, no documentation that the resident’s clinical status was monitored during this period, and no documentation that the resident was medically stable until vital signs were taken about 1 hour and 45 minutes later. When the resident was next assessed, vital signs showed an oxygen saturation of 84% on room air and a BG of 46 mg/dL. Documentation and interviews indicate the resident was unresponsive at that time, with a critically low BG and elevated blood pressure. Staff did not document application of supplemental oxygen after the low oxygen saturation was identified, and there is no documentation that ordered emergency hypoglycemia treatments (glucagon) were administered by facility staff prior to EMS arrival. EMS and hospital records reflect that staff reported the resident’s sugar had been found low earlier, that the resident had been told to eat and left alone, and that staff stated they did not have glucagon or glucose to give, despite existing orders for oral glucose tablets and glucagon nasal spray. EMS found the resident unresponsive, hypoxic, and with a BG of 24 mg/dL, and administered glucagon. The deficiency also includes failures to follow physician orders for insulin administration parameters for two other residents with diabetes. One resident with Type 2 diabetes had an order for nightly Lantus insulin with instructions to hold the dose if BG was less than 100 mg/dL, and to obtain a BG prior to administration. Review of records showed multiple dates on which no BG was assessed in the evening, yet all Lantus doses were documented as given, with no rationale or documentation of BG refusals. Another resident with Type 2 diabetes had an order for nightly Lantus with instructions to hold if BG was less than 100 mg/dL, but there was no corresponding order for routine BG assessments. Over a several-week period, only four BG readings were documented, while Lantus was administered on most nights, including nights without a recorded BG. The DON confirmed that BGs were not consistently obtained prior to insulin administration and that nurses were expected to review full order summaries to follow provider-ordered parameters.
Delayed UTI Evaluation and Treatment for Resident with Chronic Foley Catheter
Penalty
Summary
The facility failed to treat a urinary tract infection in a timely manner for a resident with a chronic indwelling Foley catheter. The resident was admitted with diagnoses including pneumonia and limitation of activities due to disability, and nursing staff documented that he was complaining of pain in the penis area. A nurse practitioner evaluated the resident and noted white to green drainage around the catheter, dark cloudy urine in the collection bag, and concern for a possible UTI, with an order placed for urinalysis and culture and sensitivity. Although the urinalysis and culture were ordered, the urine was not collected until several days later, and the culture and sensitivity was completed incorrectly and could not be resulted. The nurse practitioner was not notified that the specimen had not been collected, and documentation could not be found that the prescriber was informed of the failed lab completion. During this period, the resident was later seen for right flank pain and malodorous drainage around the catheter, and subsequently asked to be sent to the emergency room for penile pain and discharge. The emergency room diagnosed the resident with a UTI and prescribed an antibiotic.
Falls Not Prevented and Hazardous Materials Left Unsecured
Penalty
Summary
The facility failed to prevent a fall for Resident #1, a male with diagnoses including pneumonia and repeated falls, when a CNA provided bed mobility care without using the required second staff person. A facility investigation found that the CNA knew the resident required two people for safe bed mobility but proceeded anyway, and the resident fell from the bed to the floor, sustaining a cut to the forehead and a broken right distal femur. The DON stated that the CNA did not follow facility policy or the resident-centered care plan, and those actions led to the fall and fractured femur. The facility also failed to follow post-fall assessment procedures for Resident #51, a female with cognitive communication deficit, difficulty walking, muscle weakness, and lack of coordination. After an unwitnessed fall in her room, she was transferred back to bed by mechanical hoyer lift before a complete head-to-toe assessment was completed, and she then complained of right hip pain. The resident was sent to the emergency room and diagnosed with a right proximal femur fracture. In addition, hazardous materials and biologicals were left unsecured: the beauty shop door was open and unlocked cabinets contained an aerosol coolant/disinfectant/lubricant/cleaner/rust preventative and hair spray, and Resident #43 had a bottle of dermal wound cleaner on a table in her room along with a Kleen peri cleaner and a miconazole powder bottle.
Multiple Food Service Sanitation and Hand Hygiene Failures in Kitchen and Dining Areas
Penalty
Summary
The deficiency involves multiple failures in kitchen sanitation and food handling practices observed during a survey. Surveyors observed that the only designated handwashing sink in the dishwashing room did not have hand towels readily available, contrary to FDA Food Code requirements for hand drying provisions. In the dining room, the hand sink was leaking cold water, and the dietitian reported that the faucet had been repaired the prior week for the same issue, indicating the plumbing system was not maintained in good repair. Additional observations showed that the ventilation hood system over the cookline was not properly maintained. Filters were missing from the face of the hood ventilation system, and the dietitian stated the filters had been out for cleaning since several days prior and that the hood was not operational, then turned the hood off. This condition did not meet FDA Food Code requirements that ventilation hood systems be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings. Surveyors also identified improper food storage, expired products, and inadequate hand hygiene and dish sanitization practices. Resident food stored in the pantry refrigerator included a foam takeout container with an orange/brown sauce dated beyond the facility’s stated 3-day holding policy for time/temperature controlled for safety food. A Vital therapeutic nutrition supplement with an expiration date already passed was found on shelving with other therapeutic nutrition products. Kitchen personnel were observed handling clean dishes after other tasks without washing their hands, removing gloves and donning new ones without handwashing, and leaving and re-entering the kitchen to resume food preparation without washing hands, contrary to FDA Food Code handwashing requirements. The dish machine’s sanitizing rinse failed to reach the required 180°F at the gauge and 160°F plate surface temperature, with a DishTemp plate registering only 146°F, which did not meet FDA Food Code standards for hot water sanitization temperatures.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide care following professional standards of practice and facility policy to prevent the development of pressure injuries, and failed to assess, monitor, and provide ordered treatment for two residents with pressure injuries/wounds. One resident had an admission history that included stroke with left-sided paralysis and weakness. During observation, a dressing on the resident’s coccyx had multiple dates written on it, including 1/4, 1/6, and 1/7. The DON observed the dressing and stated it looked like the dates had been changed so the dressing would not have to be changed. The resident’s eTAR showed an order to clean the open coccyx area and apply Optiform every other night shift starting 1/4/26, but there was no documentation that the dressing had been changed on 1/6/26. The care plan noted the resident had a pressure ulcer and that treatments were to be administered per physician orders. The second resident had diagnoses including stroke, abnormal weight loss, and cerebral palsy, and was identified as high risk for pressure injury on a Braden Scale evaluation, later changing to moderate risk. Multiple observations showed the resident lying on her back with heels elevated, but without pillows or other offloading devices behind either side to reduce pressure; on later observations, a pillow was only slightly under the left side and the resident was not positioned to fully offload pressure on the buttocks. The resident’s last weekly skin evaluation had been completed months earlier, and the DON confirmed the resident had not had a skin assessment since July. A hospice note and nursing progress note documented open areas on the buttocks, and the provider communication log also noted open and nearly open buttock areas with foam border dressing applied. The record did not contain a comprehensive wound assessment when the skin breakdown was identified. The wound assessment completed later documented a new in-house acquired open lesion on the left coccyx, but it was completed 15 days after the wound was discovered. The treatment record showed the foam border dressing was not completed on two days in January. The care plan did not document the pressure injury identified in December or any newly implemented interventions to prevent further breakdown, and the skin integrity care plan had last been updated in 2023. Facility policy required weekly evaluation of skin alterations and pressure injuries and an individualized comprehensive care plan addressing the resident’s problem and interventions.
Fluids Placed Out of Reach for Resident With Left-Sided Paralysis
Penalty
Summary
The facility failed to ensure fluids were within reach for Resident #43, a female resident with a history of stroke causing left-sided paralysis and protein-calorie malnutrition. During an observation and interview on 01/05/26, she was eating lunch in bed and stated she could not reach the styrofoam cup of water placed on the left side of the over-bed table, but could reach it if it were moved to the right side. Review of her care plans showed no treatment plan addressing her left-sided paralysis, inability to reach with her left hand, or the need to position hydration so she could reach it with her right hand. Additional observations on 01/06/26 showed the cup of water repeatedly placed on the far-left corner of the over-bed table while she was resting in bed, out of reach. At 3:20 PM, she demonstrated that she could not reach the water cup across her body with her right arm. On 01/07/26 at 8:20 AM, she activated the call light and stated she was thirsty and wanted a drink but could not reach the cup of water that remained on the left side of the table.
Failure to Follow PEG Tube Feeding and Hydration Orders
Penalty
Summary
The facility failed to follow physician orders for a resident with a newly placed PEG tube after a stroke that caused right-sided weakness and difficulty swallowing. The resident was observed with tube feeding running while the head of the bed was positioned at 10 degrees, despite an order to keep the head of the bed elevated 30 to 45 degrees during tube feeding. The tube feed formula bag did not have the date and time the feeding was started or the ordered rate documented, and the 60-milliliter syringe used for flushes was observed sitting in a graduated basin with the barrel still inserted rather than separated to air dry as described in facility policy. The resident repeatedly stated she needed a drink and that she was very thirsty. The resident’s ordered water flushes were not being delivered as intended. The infusion pump showed that a flush rate had not been set, and the resident had not received hydration since the tube feed was initiated the prior afternoon. The previous tube feed run had ended the morning before, and the resident had not received fluids or hydration in the past 24 hours. An LPN stated she had started the tube feed and hydration flush and did not double check to ensure the hydration flush was programmed and running. The EMAR also did not show nursing sign-off for the tube feeding and head-of-bed orders on the evening of 01/02/26.
Unsafe PICC and IV Therapy Management
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not maintained for two residents receiving PICC-based IV therapy. One resident, admitted with a right femur fracture and later hospitalized for an infected prosthesis in the right femur, had a PICC in the right arm for IV antibiotics. During observation, the IV antibiotic tubing was connected to the PICC and the resident stated the tubing was stuck inside the PICC lumen. The resident also had a folded gauze dressing under the clear PICC dressing, covering the catheter entry site. The treatment record did not include a measurement of the PICC external catheter for daily monitoring, and the unit manager stated there were no measurements available. A vascular access RN later determined the tubing had been incorrectly pushed into the PICC opening instead of using a needless connector, and that the gauze dressing should not have been under the clear sterile dressing. A second resident was admitted with metabolic encephalopathy due to sepsis and had a PICC in the left arm for IV antibiotics. The admission assessment did not document the catheter size and length, arm circumference at the insertion site, or the appearance of the PICC site. The electronic treatment record also lacked orders for PICC monitoring, dressing changes, infection monitoring, catheter length monitoring, and flushing. A PA stated that if the hospital did not send orders for PICC monitoring and flushing, nursing should recognize this and call for orders. A nursing progress note later documented that the PICC was pulled by an RN/unit manager/infection control preventionist when IV medication was discontinued, and the PA stated that an order to stop IV antibiotics and remove the PICC had not been given.
Controlled Substance Count Documentation Errors
Penalty
Summary
The facility failed to account for controlled substances in one of one medication carts reviewed for narcotic reconciliation. Review of the Controlled Medication Shift Change Log for medication cart Medbridge 1 showed an incorrect total documented on 1/3/26 at 7:30 AM, and that incorrect total was carried forward through the next four shift change counts. Review of the Controlled Substance Shift Inventory sheets for Medbridge 1 dated 11/22/25 to 12/30/25 showed multiple documentation problems, including missing two-nurse signatures on several shift counts, missing end-of-shift totals on multiple entries, and incorrect counts on several dates. During interview, the DON stated that Unit Manager/RN Z was responsible for auditing the controlled substance documentation on the medication carts and confirmed that the documentation did not match the facility’s policy or expectation. The facility policy required a physical inventory of all controlled medications by two licensed nurses and documentation of the count at shift exchange, with both nurses signing to acknowledge that the actual count matched the documented quantity.
Infection Control Surveillance and PPE Failures
Penalty
Summary
The facility failed to implement an effective and current system of surveillance of staff illnesses. Review of the December employee illness log showed 32 employee call-offs, including entries such as a CNA who said she was "not feeling well," another with no reason listed, another with an unknown reason, and another reporting a "stomach bug," but none of the call-offs had documentation of specific symptoms or a return-to-work date. During interview, the ICP and DON stated that staff call-offs were tracked and discussed each morning, and that vague reasons should have been followed up to obtain accurate symptoms and a return-to-work date. The DON later confirmed that specific illnesses and return-to-work dates were not completed or acted upon. The facility also failed to ensure appropriate PPE and Enhanced Barrier Precautions for residents with wounds. Resident #36 had a right foot surgical wound with daily dressing care ordered, and Resident #58 had bilateral buttock wounds with daily foam border dressing changes ordered. Review of both residents' orders showed no EBP order, and observations on two separate occasions showed no EBP signage posted outside either room. An LPN stated that if a resident were in EBP, signage would be on the door to alert staff to wear appropriate PPE during care, and the DON confirmed that the ICP was responsible for ensuring residents were placed in EBP and that signage and PPE were posted outside the room. The facility also failed to ensure appropriate PPE was used for Resident #40, who had COVID-19 and was on Special Droplet Contact Precautions. A sign on the room door directed anyone entering to wear a gown, gloves, face shield, and N95 respirator and to keep the door closed. During observation, a maintenance assistant entered the room wearing only a blue surgical mask and left the door open approximately 3 inches while standing next to the resident's bed and talking with him. The maintenance assistant acknowledged awareness of the posted precautions, and a CNA also confirmed the resident was in isolation for COVID-19.
Poor Maintenance and Cleanliness in Resident Restrooms
Penalty
Summary
The facility failed to maintain general cleanliness and repair of ceilings and ventilation covers in resident restrooms 11, 12, and 13. On 01/15/2026 at 2:00 PM, surveyors observed cobwebs on the vent cover in the restrooms for rooms 11, 12, and 13. Record review of the Healthcare Services Group housekeeping schedule showed the cleaning resident rooms process includes a 5 and 7 step cleaning process for horizontal surfaces, vertical surfaces, dust mopping, and damp mopping. On 01/05/2025 at 2:00 PM, surveyors observed in room [ROOM NUMBER]'s restroom that a ceiling tile was sagging and partially off the ceiling grid tracks, leaving an accessible space of half an inch between the tile and the track. On 01/05/2026 at 3:15 PM, Maintenance CC stated they were unaware of the sagging ceiling tile in room [ROOM NUMBER]'s restroom.
Failure to Maintain Resident Dignity and Access to Call Light
Penalty
Summary
The deficiency involves the facility’s failure to treat a resident in a dignified manner and to honor her rights to self-determination and communication. The resident was an adult female admitted with an infected right hip replacement and difficulty walking. In an interview, she reported that very early one morning a CNA entered her room and told her to stop using her call light, stating that the CNA had already been in the room multiple times and would not be coming back again. The resident stated that the CNA then manipulated her bed controls and call light and left the room. The resident later awoke around 5:00 AM needing to use the bathroom and was unable to locate her call light to request assistance. According to the resident, because she could not find the call light, she had a bowel movement and urinated in her undergarments, which left her feeling devastated and embarrassed. Another CNA, who entered the room after shift change that morning, reported smelling feces, finding the resident very upset, and observing that the sheets were saturated with urine and feces. This CNA also reported that the call light was wrapped together with the bed remote, on the floor, out of the resident’s sight and reach. The CNA implicated in the incident was no longer employed at the facility and was not available for interview.
Failure to Notify Providers of Significant Changes and Abnormal Clinical Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify providers of significant changes in condition and abnormal clinical findings for two residents. One resident with type 1 diabetes mellitus and an order to obtain blood sugars before meals and at bedtime, with instructions to notify the physician for blood glucose levels less than 60 or greater than 200, had multiple documented blood sugar readings far above the ordered threshold. These included values in the 400–551 range on numerous dates. Review of the electronic medical record showed no documentation that the provider was notified of any of these elevated blood sugar results. When surveyors requested evidence of provider notification, the Nursing Home Administrator acknowledged there was no documentation, and the DON stated that the expectation was for licensed nurses to notify the provider of elevated blood sugars, typically when readings were greater than 450. The second resident, who had heart disease and a cardiac pacemaker, experienced an episode of left-sided chest pain for which nitroglycerin was administered. Vital signs at that time included a blood pressure of 158/90, pulse 73, respirations 18, temperature 97.3, and oxygen saturation of 93% on room air. Nursing documentation indicated that the nurse notified the resident’s wife of the condition and that she advised continued monitoring and possible hospital transfer if the condition worsened. However, there was no documentation in the electronic medical record or provider communication log that the provider was notified of this chest pain episode, despite the resident’s complex cardiac history. The DON confirmed there was no documentation of provider notification. The report cites a nursing textbook outlining failure to communicate abnormal assessment data or significant changes in status as a common negligent act.
Failure to Prevent and Monitor Misappropriation of Medications
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s medication when a nurse accepted and retained possession of a GLP-1 medication (Ozempic) for a male resident with type 2 diabetes and the medication subsequently could not be located. According to the facility-reported incident, the RN accepted the Ozempic from the pharmacy late at night and had it in her possession, then attempted to obtain a co-signature from an LPN after she already had the medication. The LPN found this concerning and reported it to the DON early the next morning. When first shift staff arrived, the Ozempic could not be found, and the packing slips for all medications delivered were recovered except for the Ozempic. Multiple co-workers reported that the RN frequently communicated or inquired about medications for weight loss. The facility also failed to adequately monitor and investigate potential or ongoing misappropriation of a resident’s narcotic medication when only one LPN dispensed all doses of a PRN narcotic (Norco) to a cognitively intact female resident over an extended period, and a missing tablet was documented without resolution. Review of the controlled drug records showed that from late October to early January, only one nurse dispensed the Norco, and an entry indicated a correct count had been completed but one tablet was missing and could not be accounted for. The resident reported that her pain was effectively controlled with scheduled Tylenol at night and that she did not request the PRN Norco. The DON confirmed that the pattern of only one nurse dispensing the narcotic appeared suspicious for diversion, and the NHA confirmed the resident’s report that she did not require the PRN Norco for pain control.
Failure to Document Resident Abuse Allegation and Related Assessments in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a cognitively intact resident with multiple psychiatric diagnoses, including dementia with agitation and psychotic disturbance, anxiety, and bipolar disorder. The resident’s admission record and MDS showed he was cognitively intact, with a BIMS score of 15. On or around late September, the resident reported to staff that a CNA had yelled at him when he complained about his roommate’s urinal being left in the bathroom, and he stated that the interaction was upsetting to him. In a typed interview statement, the resident reported that the aide spoke to him in a way he did not like, but he did not remember the aide’s name and stated he was not scared and felt safe in the facility. A CNA’s written statement documented that the resident described arguing with a specific CNA about the urinal being left in the bathroom, that he had removed it and thrown it on the floor, and that the CNA was screaming at him until an RN intervened. The CNA also documented that the resident appeared fearful and stated he would protect himself from the aide if necessary, and that she immediately reported the incident to the facility abuse coordinator. Despite these reports and the internal investigation, a review of the resident’s electronic medical record for the period surrounding the alleged incident showed no documentation of the resident’s complaint, the alleged verbal altercation, or any related behavioral episodes such as yelling or verbal aggression by either the resident or staff. Interviews with the DON and NHA confirmed that allegations of staff yelling or swearing at residents were documented only in the facility’s incident reporting system and on internal risk management forms, which are not part of the resident’s medical record. The DON stated she was unsure whether such accusations would be documented in the resident’s progress notes and indicated that staff would definitely document if a resident yelled or swore at staff, but not necessarily if staff were accused of yelling at a resident. The NHA stated that the facility did not document the resident’s initial accusation in the medical record and that related information was kept in an investigative file separate from the record. This practice resulted in the absence of any documentation in the resident’s electronic medical record regarding the allegation, the resident’s psychosocial status, or any follow-up assessments during the relevant time frame, contrary to accepted professional standards for nursing documentation as described by the American Nurses Association.
Call Lights Left Out of Residents’ Reach
Penalty
Summary
The facility failed to ensure call lights remained within reach for three residents who were reviewed for accommodation of needs. Resident #43, a female with diagnoses including stroke with left-sided weakness and paralysis, a history of falls, and lack of coordination, was observed multiple times lying in bed while her call light was on the floor under the head of the bed, out of sight and out of reach. When asked, she stated she could not find it. Her care plan included an intervention that she would use the call light to call for assistance. Resident #93, a 65-year-old female with a new PEG tube placed after a stroke causing right-sided weakness and difficulty swallowing, was observed lying across the bed and asking for a drink while her call light was on the floor at the right side of the head of the bed, out of reach and out of sight. On another observation, her call light hung off the left side of the bed halfway to the floor and was caught on tube feed tubing, pulling it taught from the resident to the infusion pump. Resident #10 was observed sitting up in bed and stated she used the call light system if she needed anything, but she could not locate it because it was on the floor near the head of the bed, out of sight and out of reach. A CNA stated that call lights were expected to be checked each time staff entered a room, and the facility policy stated staff would be educated in the proper use of the resident call system, including ensuring residents have access to the call light.
Failure to Monitor Clozapine Lab Requirements
Penalty
Summary
The facility failed to adequately monitor and ensure that one resident receiving clozapine was free from adverse drug reactions. The resident was a female admitted with diagnoses including Bipolar II Disorder, Schizoaffective Disorder, and Schizophrenia. Her orders included clozapine 100 mg by mouth three times daily, with an additional 50 mg at bedtime to equal 150 mg. The record also showed a CBC order every 60 days, and a pharmacy recommendation that ANC monitoring be updated to monthly. The resident’s last known ANC was 4858 on 2/4/25, and a provider approved changing the CBC with differential to monthly because the lab did not have a q2 month option. Despite these references to monthly monitoring, the resident’s order summary did not reflect an order for monthly CBC with differential lab draws. Psychiatry notes later documented that monthly CBC monitoring with clozapine was recommended, but no current labs were available in the chart for review. The last CBC result in the laboratory record was on 9/25/25. On 1/6/26, the facility reported there was no lab work available, and the DON stated the management team was unaware of the laboratory testing requirements for Clozaril administration and that the pharmacy had not recently requested CBC or ANC results or routine testing.
Failure to Update Isolation Care Plan for Resident with COVID-19
Penalty
Summary
The facility failed to update the care plan for one resident, R40, within 7 days of the comprehensive assessment and did not have the care plan prepared, reviewed, and revised to reflect the resident’s current isolation status. R40’s admission record showed multiple diagnoses, including contact with and suspected exposure to COVID-19. A sign posted outside the resident’s room on 01/06/2026 indicated the resident was in isolation and required Special Droplet Contact Precautions, including gown, gloves, face shield, and N95 respirator for anyone entering the room. During interview, a CNA confirmed the resident was in isolation for COVID-19 and that Special Droplet Contact Precautions were to be followed. A provider encounter note dated 12/20/25 documented that the resident had COVID-19 infection, had tested positive in the facility after symptoms of cough and nasal drainage, and remained in bed with stable oxygen saturations and vital signs. However, the resident’s care plans dated 8/13/24 to 1/6/26 showed only one barrier/isolation-related care plan for Enhanced Barrier Precautions, dated 9/20/24, and no updated care plan for Special Droplet Contact Precautions despite the COVID-19 diagnosis. The resident’s Kardex also failed to show any contact precautions. The NHA stated the facility had a new Infection Preventionist and DON and that staff were focused on orders and signage, so adding the care plans was overlooked; she also stated the updated information should have been on the resident’s Kardex.
Weights Not Obtained as Ordered for Residents With Edema and CHF
Penalty
Summary
The nursing facility failed to ensure that resident weights were obtained in accordance with physician orders for 3 of 5 residents reviewed for nursing services. Resident #11 had an order to monitor weight weekly for edema, but the record showed multiple weeks when no weight was obtained, weights were reused from prior dates, or the weight documented on the MAR did not match the weight actually obtained in the Weight Summary. The EMR contained no documentation that the resident refused to be weighed or any rationale for not obtaining the ordered weights. Resident #23 had an order for weights three times weekly for CHF, but the MAR showed weights from 12/17/25 being used on 12/19/25 and 12/22/25 without new weights being obtained, and there was no documentation of refusal or rationale for not weighing the resident. Resident #55 had an order for weights twice weekly for edema, but the TAR showed the 12/18/25 weight being reused on 12/22/25 and 12/25/25 without new weights being obtained, and the EMR also lacked documentation of refusal or a reason for not obtaining the ordered weights. During interview, the DON confirmed the weights were not obtained as ordered and stated nurses were expected to obtain the weights or document the rationale for not obtaining them.
Failure to Initiate Bowel Protocol for Constipation
Penalty
Summary
The facility failed to initiate the bowel protocol for one resident who was reviewed for constipation. The resident was an older female with dementia who had reported constipation during an interview and could not recall whether she had received any medication to relieve it. Review of the bowel elimination monitoring record showed a bowel movement on 12/10/25 in the afternoon, with the next documented bowel movement not occurring until 12/20/25 in the evening, a 10-day gap. The electronic medication administration record showed an order for Milk of Magnesium 2400 mg/30 mL, to be given 30 mL by mouth every 24 hours as needed for constipation and for bowel movement protocol when there was no bowel movement in 72 hours. The medication was not administered until the night of 12/19/25, after 9 days without a bowel movement. During interview, the Regional Clinical Nurse stated the facility does not have standing orders for bowel protocol and that nurses follow the PRN orders in the eMAR. The resident’s care plan identified constipation risk and included a goal of having a normal bowel movement at least every 3 days, with interventions to administer medications as ordered, follow the facility bowel protocol, and monitor, document, and report signs and symptoms of constipation complications.
Failure to Include Required Dose Amount for Voltaren Gel
Penalty
Summary
The facility failed to implement a physician-approved pharmacy recommendation for a resident admitted with dementia, PTSD, and chronic pain. The consultant pharmacist reviewed the resident’s medication regimen and noted that the order for Voltaren Gel (diclofenac sodium) did not specify the quantity to be used with each dose or the maximum amount per joint per day, and recommended that the physician write the order with those details. The physician agreed with the recommendation, but the resulting order for diclofenac sodium 1% gel to be applied to both knees four times a day still did not include a specified quantity or total amount per day. A review of the MAR showed the resident received an unspecified amount of diclofenac sodium 1% gel with each dose and an unspecified total amount per joint to both knees four times a day from the order date through the day of review, including one dose administered the morning of the survey. During interview, the DON stated she was aware that Voltaren gel should have an amount per dose and a maximum total amount per joint per day, and stated she knew the maximum amount for knee joints was 16 grams per joint per day, or 32 grams for both knees combined. The manufacturer’s instructions reviewed by surveyors stated that 4 grams should be applied to each lower body area four times a day.
Failure to Monitor Vital Signs Before Administering BP-Dependent Medications
Penalty
Summary
The facility failed to adequately monitor vital signs and administer medications in accordance with physician orders for 2 residents reviewed for unnecessary medication. Resident #6 was admitted with diagnoses including heart disease and heart failure and had an order for Midodrine 10 mg via G-tube three times daily for a dialysis patient, with instructions to hold for SBP greater than 120 and to administer at 9:00 AM, 1:00 PM, and 9:00 PM. Review of the blood pressure summary and MAR showed that on multiple days, blood pressure was not assessed prior to scheduled doses, yet the medication was still administered. On 1/4/26, the resident’s blood pressure was 129/42 at 6:10 PM and the 9:00 PM dose was administered despite being outside the ordered parameters. Resident #10 was admitted with a diagnosis of hypertension and had an order for Lasix 40 mg by mouth twice daily for edema, with instructions to hold for SBP less than 110 and to administer at 8:00 AM and 2:00 PM. Review of the blood pressure summary and December-January MAR showed that blood pressure was not obtained before several scheduled doses, and in some instances a prior blood pressure reading was used for both doses. On 12/21/25, Lasix was held for both doses even though the documented SBP was 110, not less than 110, and on 12/25/25 the 2:00 PM dose was held despite the documented SBP being greater than 110. During interview, the DON confirmed that vital signs were not obtained prior to each administration as ordered and stated that licensed nurses were expected to follow the ordered parameters and obtain vital signs before administering the medications.
Incomplete Lab Monitoring and Missing Results for Residents on Warfarin
Penalty
Summary
The facility failed to ensure laboratory tests were completed and laboratory results were obtained for 3 of 18 residents reviewed for laboratory services. For a resident admitted with heart disease and a cardiac pacemaker who was receiving warfarin, the record showed repeated gaps in PT/INR monitoring. The chart contained no Coumadin flowsheet and no anticoagulant monitoring schedule in the care plan. Orders for PT/INR were entered multiple times, including one-time and next-lab-day orders, but several results were not available in the record, and the Director of Nursing confirmed that the Coumadin flowsheet and multiple PT/INR results were not completed or available. The resident also received cefuroxime axetil for acute cystitis, and the record did not show documentation that increased PT/INR monitoring was considered. For another resident admitted with atrial fibrillation and discharged on home warfarin with a plan to check INR 3 times weekly, the record again showed no Coumadin flowsheet and no anticoagulant monitoring schedule in the care plan. The hospital discharge notes, provider communication book, nursing admission note, and physician history and physical all referenced INR monitoring, including an order for INR on 12/26/25. However, the electronic record contained no documentation explaining why the PT/INR was not obtained on that date. The DON confirmed that the resident did not have the ordered PT/INR drawn on 12/26/25, and the lab result that was eventually reviewed by the provider was not addressed until after the resident had been discharged from the facility. For a third resident, a physician order form reflected a lipid panel order, but during record review the NP identified that the ordered lipid panel had not been completed. The DON also reported ongoing issues with the contracted laboratory company obtaining and resulting specimens timely. Staff interviews further confirmed that the Coumadin flowsheets were located in the electronic record under the Assessments tab, but the required monitoring documentation was not present for the residents reviewed.
Failure to Implement Antibiotic Stewardship and Complete Ordered Antibiotics
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for 2 of 7 residents reviewed for antibiotic use. For one resident admitted with acute kidney failure, a provider documented cloudy, malodorous urine and mild lethargy, but the record contained no documented UTI symptoms outside that note before the urine culture was obtained. The urine specimen was collected several days later, the culture resulted after that, and nitrofurantoin was not started until 10 days after the initial provider note. The infection control worksheet listed a symptom onset date and indicated McGeer Criteria were met, although the record did not document constitutional criteria or other clinical symptoms to support that determination. For that same resident, the antibiotic was not administered as ordered. The medication administration record showed the first scheduled doses were missed, and the electronic administration notes stated the doses were not given because the medication was on order. The automated medication dispensing system printout showed no Macrobid was pulled from stock on the dates the doses were missed. The provider communication book also documented missed antibiotic doses. A second resident, admitted with end stage renal disease, was transferred to the hospital for workup and later returned with a diagnosis of acute cystitis and a prescription for cefuroxime. The record contained no documented UTI symptoms before the hospital transfer, and the urine culture later showed no growth of bacteria with only resident flora detected. The infection control worksheet again listed a symptom onset date and indicated McGeer Criteria were met despite no documented clinical symptoms. The antibiotic was also not administered in full as ordered, with missed doses documented as out of stock, waiting on pharmacy, and not in the automated medication dispenser. During interview, the Infection Control Preventionist and DON stated the ICP was responsible for following up on cultures and susceptibility, and the DON and Regional Clinical Nurse later confirmed the ordered antibiotics should not have been missed because they were available in the automated medication dispensing system.
Failure to Thoroughly Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who eloped from the facility and was found outside in the parking lot. The incident report stated staff noticed the resident was not in his room after an outside door alarmed, searched for him, and brought him back inside with no obvious injury observed. The facility initiated a head-to-toe assessment and 15-minute checks, but the subsequent investigation did not fully document the circumstances surrounding the elopement. During survey observation and record review, the elopement risk information was found to be inaccurate. The list of residents at risk for elopement did not have correct room numbers for one resident observed with a wander alert device, and the elopement risk binders at two nurse stations and the front reception area were not up to date for 4 of 9 residents identified by the facility as at risk for elopement. The maintenance director also reported he did not know one staff entrance door was equipped with a wander guard sensor, and he stated the laundry room door had been alarming frequently before the resident eloped, contributing to alarm fatigue among staff. The investigation also lacked key witness statements and details. A CNA reported she turned off the laundry room alarm, looked outside, and returned to her duties without physically going outside to verify who had triggered the alarm. An LPN reported she did not complete a face-to-face head count of residents on the unit and had not participated in an elopement drill on the night shift. The completed investigation did not include statements from the nurse assigned to the resident, the nurse who first made contact with the resident outside, or the resident’s friend whom staff believed he may have been trying to visit. The NHA also reported the facility had not documented who last saw the resident, how he was dressed, or what his behaviors were before the elopement, and the investigation did not show that a face-to-face head count of all residents had been conducted at the time of the incident.
Failure to Develop and Revise Elopement Risk Care Plans
Penalty
Summary
The facility failed to review and revise care plans for three residents who were identified as having wandering or elopement risk. Resident 1 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, muscle weakness, lack of coordination, and abnormal gait and mobility. Records showed that R1 had a history of wandering behavior, including a psychiatry note documenting complaints of always trying to stand and walk and identifying wandering related to cognitive impairment, and social work notes showing the facility was seeking memory care placement. An interdisciplinary team note later documented that the wander guard was discontinued because R1 had settled into the facility and was not wandering or pushing on doors. Despite those findings, the care plan for exit seeking/elopement risk was not initiated until the same day R1 successfully eloped from the facility and was found outside in the parking lot. The incident report stated staff noticed R1 was not in his room, searched for him, and brought him back inside. The record also showed that R2 had been identified as at risk for elopement on two elopement risk evaluations and had a wander alert device order in place, but the care plan report showed no care plan for wandering or elopement until later. R4, admitted with diagnoses including dementia, bipolar disorder, insomnia, cognitive communication deficit, and altered mental status, had multiple wandering risk assessments and elopement risk evaluations showing risk for wandering and elopement, yet the care plan for exit seeking/elopement risk was not implemented until later as well. During interview, the NHA and Regional Nurse Consultant stated they were not aware care plans were not in place for some residents identified as being at risk for elopement. Facility policy required that when a resident is at risk for elopement, a care plan be developed with exit-seeking/elopement risk interventions, and the comprehensive care plan policy stated that care plans are developed for each resident and revised as conditions change. The record review showed that these care plans were not developed or revised in a timely manner for the identified residents.
Elopement Monitoring and Response Failure
Penalty
Summary
The facility failed to fully implement its elopement policy and procedure for a resident who was admitted with hemiplegia and hemiparesis following cerebral infarction, vascular dementia, muscle weakness, lack of coordination, and abnormal gait and mobility. The resident’s quarterly MDS reflected severe cognitive impairment, with a brief interview for mental status score of 6/15, and the resident required substantial to maximal assistance with dressing and footwear and was dependent on staff for lower body dressing and putting on and taking off footwear. A reported incident stated that an outside door was alarming and staff noticed the resident was not in his room. Staff searched and found him outside in the facility parking lot, then brought him back inside. The incident report stated no obvious injury was observed, the resident was smiling, and a head-to-toe assessment and 15-minute checks were implemented. During survey observation, the facility’s elopement risk list was found to be inaccurate, including an incorrect room number for a resident at risk who wore a wander alert device, and the elopement risk binders at two nurse stations and the front entrance showed resident profiles and admission records that were not up to date with current room numbers for 4 of 9 residents identified as at risk for elopement. Survey findings also showed the wander guard alarmed staff entrance door was not routinely tested, and the Maintenance Director reported he did not know that door was equipped with a wander guard sensor. He also reported ongoing trouble with the laundry room door alarming frequently before the resident eloped, contributing to alarm fatigue among staff. A CNA stated she heard a door alarm, assumed it was the front door, turned it off, looked outside but did not physically go out to verify who had triggered it, and then returned to her duties. The completed incident report did not reflect that a face-to-face head count of all residents had been conducted when the resident eloped, and staff interviews indicated they did not conduct such a count and had not participated in an elopement drill on the night shift.
Untrained Staff Paused and Restarted Enteral Feeding
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) paused and restarted enteral tube feeding for a resident diagnosed with esophageal cancer and esophageal obstruction, who was receiving enteral nutrition per physician's orders. The CNA reported pausing the tube feeding prior to providing care and then restarting it afterward, despite not being trained or authorized to perform this task. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that only trained staff, such as licensed nurses and med techs, were permitted to pause and restart tube feedings. Additional staff interviews revealed that CNAs regularly performed this action, indicating a lack of adherence to facility policy regarding tube feeding management.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, which is a critical aspect of accommodating their needs and preferences. Resident #305, a female with dementia, unsteadiness, cognitive communication deficit, and lack of coordination, was observed multiple times with her call light on the floor, out of sight and reach. Despite requiring assistance for daily activities, she stated she would manage on her own, indicating a lack of awareness or ability to use the call light effectively. Observations on consecutive days showed the call light consistently out of reach, whether she was in bed or in a wheelchair. Another resident in bed 104-A was also found with the call light cord hooked through the bed frame, leaving the call light on the floor and inaccessible. This resident was awake and watching television but was unaware of the call light's location when asked. A CNA confirmed that staff are expected to check call light placement each time they enter a room, suggesting a lapse in adherence to this protocol. These observations highlight a failure in ensuring residents can alert staff when needed, compromising their ability to receive timely assistance.
Medication Administration Discrepancy for Resident with Seizure Disorder
Penalty
Summary
The facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident, a male with a history of seizure disorder, frequent falls, weakness, and unsteadiness, was prescribed Vimpat (Lacosamide) 50 mg twice daily. A review of the Control Substance Record indicated that the medication was last administered on the morning of January 12, 2025, and had run out, with no additional pills available until January 16, 2025. Despite this, the Electronic Medication Administration Record (Emar) showed that the resident was given a dose of Vimpat on the evening of January 14, 2025, which was not accounted for in the Control Substance Record. During an interview, the Unit Manager confirmed that the Vimpat was not available in the facility on the evening of January 14, 2025, and could not explain why it was recorded as administered. This discrepancy indicates a failure to maintain accurate and complete documentation of medication administration, as required by professional standards. The report highlights the importance of ensuring that medication records are truthful and complete to maintain the quality of care for residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact-Based Precautions for three residents, leading to deficiencies in infection control. One resident, who was cognitively intact and required extensive assistance, had a sign on their door indicating the need for EBP, including wearing gloves and a gown. However, two nurses entered the room with only gloves, disregarding the gown requirement. Another resident, admitted with a wound infection and paraplegia, was placed on EBP but did not have Contact Precautions implemented until over six weeks later, despite a physician's order. Similarly, a third resident with sepsis was not placed on Contact Precautions until 25 days after admission, despite being on EBP. The facility also failed to follow policies and procedures for IV administration for one resident. During an observation, a nurse was seen using undated tubing for an IV antibiotic and did not disinfect the port before reconnecting the tubing. The nurse admitted to not having an answer for why the port was not cleaned and mentioned a lack of tubing as a reason for the improper practice. This failure to adhere to IV administration protocols posed a risk of infection for the resident. Additionally, the facility did not implement its water management plan to reduce the risk of legionella and other pathogens, potentially affecting all residents. A water analysis revealed abnormal levels of legionella, but the facility did not take the required remedial actions, such as enhanced monitoring or notifying the Regional Director of Maintenance. The Director of Maintenance admitted to not being familiar with the entire water management plan, and housekeeping staff were not properly instructed to flush sinks, as required by the plan.
Failure to Assess and Supervise Self-Administration of Medication
Penalty
Summary
The facility failed to perform a resident assessment and obtain a physician order for the self-administration of a breathing treatment for a resident, resulting in the resident self-administering a nebulizer treatment without appropriate supervision and assessments. The resident, identified as R225, was admitted to the facility with diagnoses including pneumonitis, heart disease, lack of coordination, and blindness in one eye. During an observation, it was noted that R225 was in his room starting a breathing treatment without being assessed by the registered nurse (RN) present, who also did not perform a post-assessment after the treatment was completed. The Medication Administration Record (MAR) indicated an order for Arformoterol Tartrate Inhalation Nebulization Solution to be administered twice daily for COPD. However, there were no orders, assessments, or care plans for the self-administration of medications in the resident's electronic medical record. The facility's policy on self-administration of medications requires an interdisciplinary team assessment and periodic re-evaluation, which was not conducted for R225. Additionally, a Licensed Practical Nurse (LPN) admitted that nurses are supposed to stay with residents during nebulizer treatments but cited time constraints as a reason for not doing so.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and assess the use of psychotropic medications for a resident identified as R19. The resident, who was admitted with diagnoses of schizoaffective disorder, bipolar disorder, and PTSD, was observed to be tearful and intermittently crying during an interview. The care plan for R19 included administering medications as ordered and monitoring for side effects and effectiveness, yet there was no documentation of such monitoring in the medical records. A behavioral health document indicated that hydroxyzine was discontinued, and the plan was to monitor for changes in mood or behaviors for 14 days, but this monitoring was not documented. During an interview, an LPN confirmed that there was no documentation in the MAR for monitoring R19's behaviors or side effects of psychotropic medications, although such monitoring was documented for another resident. This lack of documentation and monitoring represents a failure to adhere to the facility's policy on psychoactive drug use, which aims to prevent excessive dosing, duration, and ensure adequate monitoring and indications for use.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and date mark opened medications, dispose of expired medications, and secure medication carts. During an observation of a medication cart on the 100 hall, it was found that a Flex Touch 1000 insulin pen, which should have been refrigerated until opened, was improperly stored in the cart. Additionally, a vial of Lantus insulin, two bottles of Systane eye drops, Polymyxin antibiotic eye drops, and Dorzolamide/Timol eye drops were not labeled with the resident's name or the date they were opened. A registered nurse confirmed these labeling issues and acknowledged that the insulin pen should have been refrigerated. Furthermore, a personal belonging, specifically a large black purse, was found stored in a medication room, which was confirmed by the unit manager to be inappropriate. The facility's Medication Access and Storage Policy, adopted on 7/11/2018, did not address the labeling of medications, which contributed to the deficiencies observed. Additionally, during separate observations, two medication carts were found unlocked and unattended in the hallways. In one instance, an LPN admitted to forgetting to lock the cart, and in another, a medication treatment cart was left unlocked with no nurses in view. The LPN responsible for the cart confirmed that it should have been locked when unattended. These lapses in securing medication carts and improper labeling and storage of medications highlight significant deficiencies in the facility's medication management practices.
Lack of Coordinated Hospice Care for Two Residents
Penalty
Summary
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. Resident R16, a female with multiple sclerosis and neuromuscular dysfunction, was observed to be unaware of the hospice staff's visit schedule, except for a hospice aide who visited on Wednesdays without a set time. The facility's social worker could not find documentation confirming hospice participation in R16's care conferences, and there was no record of weekly hospice visits in her electronic medical records. An email request for hospice records revealed that the hospice aide provided weekly showers, but it was unclear if other services were provided. Resident R41, a female with hemiplegia, dysphagia, and chronic kidney disease, reported severe stomach pain and was receiving Tylenol for pain management. The RN was unaware of the hospice staff's visit schedule for R41. The facility's social worker could not locate documentation of hospice participation in R41's care conferences, and the last hospice records were dated over a week prior. Progress notes indicated that R41 experienced severe pain and nausea, but there was no indication of hospice notification regarding her condition change. The facility's NHA found documentation that R41 refused hospice nurse aide services, but there was no explanation for the lack of hospice nurse documentation in her medical record.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident, identified as Resident #29, who was reviewed for immunizations. Upon admission, the resident had pertinent diagnoses including heart disease and hypertension and was due for the pneumococcal vaccine PCV20. The Michigan Care Improvement Registry indicated that the resident was due for this vaccine since admission, and the resident had consented to receive it. However, the resident's electronic health record showed the pneumococcal status as pending. The Director of Nursing acknowledged that the vaccine was due upon admission and should have been scheduled by the unit manager, but this did not occur. Additionally, there was uncertainty about whether the Infection Preventionist had a process to ensure timely offering of pneumococcal vaccines to residents. The facility's policy stated that all residents should be offered pneumococcal vaccines upon admission unless contraindicated or previously vaccinated.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 287 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wyoming
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Post Acute Center | 1.2 mi | ★★★★★ | 11 | 0 |
| Corewell Health Rehabilitation & Nursing Center - | 2.9 mi | ★★★★★ | 7 | 0 |
| Optalis Health And Rehabilitation Of Grand Rapids | 3.1 mi | ★★★★★ | 34 | 2 |
| Medilodge Of Wyoming | 3.8 mi | ★★★★★ | 0 | 0 |
| Beacon Hill At Eastgate | 3.8 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.