Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wyoming Healthcare Center during CMS and state inspections, most recent first.
Incomplete and Non-Person-Centered Activity Care Plans: The facility used the same activity care plan focus statement for multiple residents instead of making the plans person-centered, and an Activity Director confirmed the plans were not individualized. For another resident, the care plan did not include the required 1:1 sensory activity intervention even though staff were providing sensory activities such as poppers and other items in the resident's room.
Inaccurate MDS Dental Status Assessment: A resident was observed with a missing front tooth on the upper denture plate, but the MDS Section L stated the dentures were not broken. Record review and DON confirmation showed the dental status entry did not match the resident’s actual condition.
PASARR screening for mental disorders or intellectual disabilities was not kept accurate in coordination with the MDS for a resident with multiple psychiatric and neurologic diagnoses, including schizoaffective disorder, paranoid personality disorder, bipolar disorder, vascular dementia, Parkinson’s disease, epilepsy, hallucinations, and anxiety disorder. The MDS listed several related diagnoses, but the most recent PASARR did not mark seizure disorder, paranoid disorder, or affective bipolar disorder even though they were present on admission, and the DON acknowledged the PASARR needed to be updated after the resident’s hospital readmissions.
Care Plan Not Updated After Quarterly Assessment: A resident’s comprehensive care plan was not reviewed or revised after a quarterly MDS assessment was completed, and the target dates were not updated. The DON confirmed the care plan had not been updated since the listed target date and acknowledged it should have been revised after the assessment.
A resident with documented hearing and vision impairments was observed without a hearing device and reported waiting for new hearing aids and glasses. Although consent was on file, the facility had no evidence the resident was ever seen by the audiologist or optometrist, despite the impairments being identified on the admission MDS.
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, and depression had psychotropic-related medication orders reviewed by the consultant pharmacist. The pharmacist identified an irregularity and asked the Medical Director to reassess a PRN psychotropic order and consider updating the order or discontinuing it, but no action had been taken and the DON acknowledged the item had been missed.
A resident in a LTC facility engaged in multiple incidents of inappropriate touching, verbal threats, and physical aggression towards other residents. The facility failed to document, investigate, or report these incidents, preventing victim identification and necessary interventions. Staff interviews revealed a lack of awareness and action, with the resident's behavior escalating after returning from a behavioral health hospital.
The facility did not ensure that all dietary staff had food handlers cards, as required by Virginia code S16-2-16. A Culinary Aide had been working since January without the necessary certification, which the Culinary Director attributed to the aide's weekend-only schedule. This oversight could potentially impact more than a limited number of residents, with a facility census of 55.
The facility failed to maintain food safety and sanitation standards, as observed during a kitchen tour. Incomplete temperature logs, expired pinto beans, a dirty microwave, and a dented can of corn were found. The Culinary Director acknowledged these issues, which could potentially affect more than a limited number of residents.
The facility did not have the required members present at a quarterly Quality Assessment and Assurance meeting, as the Medical Director was absent. This was confirmed by the DON and had the potential to affect all 55 residents.
The facility failed to maintain a clean environment in the dining room, as the ceiling around the vent was observed to be dirty during lunch meals. Despite confirmation from the Director of Plant Maintenance that cleaning was needed, the area remained unclean in subsequent observations, potentially affecting many residents.
A resident engaged in multiple incidents of abuse and aggression towards other residents, including inappropriate touching and verbal threats. Despite documentation in progress notes, the facility failed to investigate or report these incidents to state agencies. The Administrator and Unit Manager were unaware of the victims' identities and confirmed no investigations were conducted.
The facility failed to implement comprehensive care plans for residents, including daily 1:1 visits, accurate diagnosis documentation, and proper interventions for trauma and dementia. Additionally, fall prevention and tube feeding protocols were not followed, leading to incomplete care. These deficiencies were confirmed through staff interviews and observations.
The facility failed to treat residents with dignity, as one resident was left in a soiled shirt during activities, and another experienced a delay in receiving appropriate pain medication. An LPN administered Tylenol instead of the scheduled oxycodone due to a delay in accessing the medication.
A facility failed to document a resident's schizoaffective disorder on their quarterly MDS. Although the FNP recommended adding the diagnosis alongside bipolar disorder, only the latter was recorded. This omission was confirmed by the Corporate Nurse, Regional Director, and Administrator during an interview.
A facility failed to update the PASRR for a resident diagnosed with major depressive disorder after admission. Initially assessed in 2010 with no mental illness, the resident's 2017 diagnosis was not reflected in the PASRR. The DON acknowledged the outdated PASRR during an interview.
A facility failed to include a diagnosis of schizoaffective disorder in the PASARR for a resident, despite the diagnosis being made prior to admission. This omission was confirmed by the Regional Director and Corporate Nurse during an interview.
A facility failed to update a resident's care plan after discontinuing the use of a vest for positioning. The care plan still listed the vest, but observations showed the resident without it. A nurse aide confirmed the vest had not been used for some time, and the DON acknowledged the change to a seat belt, agreeing the care plan needed revision.
The facility failed to complete neurological assessments for two residents after falls, did not notify a physician of a resident's hyperglycemia, and missed doses of a diabetes medication for another resident due to availability issues. These deficiencies were confirmed by the DON.
A resident's toenail care was neglected due to a failure in the facility's process for obtaining external services. The resident's husband reported the issue, and staff interviews revealed that the resident was deemed ineligible for contracted services, with no follow-up action taken. The DON confirmed the staff's discomfort in addressing the toenail condition.
The facility failed to implement safety interventions for two residents, leading to potential accident hazards. A resident's bed bolsters were not in place as per their care plan, and another resident with a history of wandering did not have a wanderguard device ordered until after surveyor intervention, despite previous elopement incidents.
A resident receiving enteral feeding did not receive appropriate care, as an LPN failed to administer medications correctly, omitted required water flushes, and did not check gastric residual volume. The LPN also administered feeding late and did not complete medication doses, leading to a deficiency in care.
A facility failed to assess a resident for bed rail safety, as observed during a survey. Bed rails were installed without a proper safety evaluation, and the resident's care plan did not include bed rails. A Corporate RN confirmed the lack of a safety evaluation and was unfamiliar with the process.
An LPN at a facility failed to properly administer medications and enteral feeding to a resident with a feeding tube. The LPN did not administer the entire medication mixture, failed to flush the feeding tube, and did not check the gastric volume residual before administration. The facility could not provide evidence of the LPN's competencies in feeding tube care upon hire.
A resident with dementia exhibited worsening behaviors after returning from a behavioral health facility, including aggression and elopement attempts. Despite these changes, the facility failed to notify the physician until surveyor intervention, resulting in an Immediate Jeopardy situation.
A resident experienced multiple medication administration errors by an LPN, resulting in a medication error rate of 16.67%. The LPN failed to administer full doses of medications, omitted required water flushes, and did not check gastric residual volume. Additionally, medications were not administered on schedule, contributing to the high error rate. The DON was notified of these errors.
The facility failed to maintain accurate and complete medical records for two residents. One resident's transfer form had an incorrect date, while another resident's POST form was missing the date for signatures. These discrepancies were confirmed by the Administrator and the Corporate RN.
Incomplete and Non-Person-Centered Activity Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for Residents #5, #19, and #39. During record review, all three residents had the same activity care plan focus statement that read, "Resident is self-directed for activities in and out of the room daily, and Resident is dependent on staff for activities, cognitive stimulation or social interaction." On interview, the Activity Director stated that not all residents were independent and dependent on activities and said she could edit the care plans and get them fixed, confirming the plans were not person-centered for each resident. The facility also failed to include required 1:1 sensory activity interventions in Resident #23's care plan. Record review showed the resident was to receive sensory activities daily, and observation found an Activities Leader in the resident's room providing a sensory activity with poppers, but the resident was not very interested and the Activities Leader left the room. The Activities Leader stated that some residents receive sensory activities daily or every other day, either in their rooms or in a group setting, and described activities such as lotion, dolls, squeeze balls, poppers, games, play dough, or coloring. Review of the care plan showed no 1:1 activity intervention in place, and the Activity Director stated the care plan should reflect the resident being on 1:1 sensory activities but confirmed that it did not.
Inaccurate MDS Dental Status Assessment
Penalty
Summary
Resident #57’s MDS was inaccurate in the area of dental status. During observation, the resident was noted to be missing the front tooth of the upper denture plate. A subsequent record review showed that the MDS dated [DATE] stated in Section L that the resident’s dentures were not broken, which did not match the resident’s actual condition. The DON later provided a copy of the MDS and confirmed that it was incorrect.
PASARR and MDS Diagnoses Were Not Kept Consistent
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not kept accurate in coordination with the MDS for one resident reviewed during the annual survey. The resident had multiple documented diagnoses related to mental illness and neurologic disease, including depression, schizoaffective disorder, paranoid personality disorder, bipolar disorder, vascular dementia, Parkinson’s disease with dyskinesia, epilepsy, hallucinations, and later anxiety disorder. The MDS Section I dated 10/10/25 listed non-Alzheimer’s dementia, Parkinson’s disease, seizure disorder or epilepsy, anxiety disorder, depression, bipolar disorder, and psychotic disorder, while the most recent PASARR was completed on 09/12/25 by an acute care hospital.
Care Plan Not Updated After Quarterly Assessment
Penalty
Summary
Failure to develop and revise the comprehensive care plan within 7 days of the comprehensive assessment was identified for Resident #4. The resident’s record showed a comprehensive care plan with a target date of 10/24/25 for all goals, and a quarterly MDS assessment had been completed in early October 2025. However, the care plan was not reviewed or updated when that quarterly assessment was completed, and the target dates were not revised. There was no evidence that the care plan had been reviewed or updated on or after 10/24/2025. During an interview on 11/18/25 at 1:00 p.m., the DON confirmed that the care plan had not been updated since 10/24/25 and acknowledged that it should have been revised after the quarterly assessment was completed.
Failure to Arrange Audiology and Optometry Services
Penalty
Summary
The facility failed to ensure that necessary hearing and vision services were provided and maintained for Resident #55, who was identified on the admission MDS as having both hearing and vision impairments. On 11/17/25, the resident was observed without a hearing device and stated they were waiting for new hearing aids and new glasses. Record review on 11/19/25 showed the resident had a signed consent for audiology and optometry services, but the facility had no evidence that the resident was ever seen by either the audiologist or the optometrist for evaluation of the reported hearing and vision needs. During an interview on 11/19/25, the administrator confirmed there was no evidence the resident had been evaluated despite the documented impairments identified on the admission assessment in 02/2025.
Failure to Respond to Pharmacist Medication Regimen Review Irregularity
Penalty
Summary
The facility failed to ensure the Medical Director responded to the consultant pharmacist’s irregularity report from the monthly medication regimen review for one resident. Resident #6 had diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, anxiety disorder, and major depressive disorder. The resident’s medication orders included hydroxyzine HCl 25 mg twice daily for anxiety, sertraline 100 mg daily for depression, and trazodone 25 mg at bedtime for depression. The consultant pharmacist identified an irregularity on the medication regimen review and requested that the Medical Director reassess the PRN psychotropic order and consider updating the order to include an initial duration of 14 days or discontinuing the order if appropriate. The irregularity report was not initially located in the medical record and was later provided by the DON. At the time of review, the Medical Director had not taken any action on the recommendation, and the DON acknowledged that this had been missed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident who inappropriately touched, verbally, and physically assaulted other residents. The facility did not properly document, investigate, or report these incidents, which prevented the identification of victims and the provision of necessary services to them. This lack of action resulted in physical and psychosocial harm to the victims and placed all residents at risk of serious harm or death. Resident #213 was involved in numerous incidents of inappropriate behavior, including touching female residents inappropriately, making threatening statements, and engaging in physical altercations with other residents. Despite these behaviors being documented in progress notes, the facility failed to cross-reference these notes with incident logs, leading to a lack of investigation and reporting. The resident's behavior was known to escalate, particularly after returning from a behavioral health hospital, yet the facility did not implement effective interventions to manage these behaviors. Interviews with facility staff revealed a lack of awareness and action regarding the resident's abusive behavior. The Administrator and Unit Manager were unable to identify the victims or confirm any interventions in place during evenings and weekends. The Social Services Designee noted that the resident had a history of similar behaviors and expressed a desire to be removed from the facility. Despite these known issues, the facility did not maintain direct supervision of the resident, further contributing to the risk of harm to other residents.
Removal Plan
- Resident #213 was placed on 1:1 direct observation with a facility staff member until physician interventions are successful in managing behaviors.
- An immediate fax reporting of allegation was completed and sent to OHFLAC.
- The physician was notified with new orders as follows; increased Trazadone to 150mg at bedtime, changed his Paxil to bedtime, and 1 on 1 with staff member.
- The resident's care plan was updated with new orders and 1:1 observation intervention.
- All alert residents were interviewed by the Unit Managers to identify other concerns and no other issues were identified.
- All staff members were immediately re-educated on reporting allegations of abuse immediately to OHFLAC, APS, Ombudsman or other licensing board as warranted by the Unit Manager.
- All staff were educated on notifying a supervisor of any allegation immediately to assist with interventions necessary for immediate protection of residents.
- All staff not available will be re-educated on reporting allegations of abuse and notifying a supervisor immediately prior to the start of their next scheduled shift.
- The Unit Managers will monitor progress notes daily to identify potential concerns of abuse.
- The Administrator and Director of Nursing will review incident and accident reports to identify potential concerns.
- Any allegations will be reported to OHFLAC, Ombudsman, APS and other licensing boards as warranted.
- All allegations of abuse and neglect will be reviewed at the facilities Quality Assurance and Performance Improvement meeting each month.
Failure to Ensure Dietary Staff Certification
Penalty
Summary
The facility failed to employ qualified dietary staff by not ensuring that each member of the dietary staff obtained food handlers cards before working in the dietary department. This deficiency was identified during a record review and staff interview, which revealed that a Culinary Aide (CA) had been working in the dietary department since January 2, 2024, without a food handlers card. The Culinary Director (CD) acknowledged the oversight, explaining that the CA only worked weekends, making it difficult to ensure they obtained the necessary certification. This failure to comply with the Virginia code S16-2-16, which mandates food safety certificates for food employees, has the potential to affect more than a limited number of residents, with the facility census being 55.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner and maintain sanitary equipment, which could potentially affect more than a limited number of residents. During a kitchen tour, it was observed that the breakfast temperature logs were incomplete due to new employee training. The Culinary Director (CD) confirmed the logs were not filled out, suggesting they might have been misplaced during the training process. Additionally, a container of pinto beans with an expired date was found in the reach-in refrigerator, which the CD acknowledged and disposed of immediately. Further observations revealed unsanitary conditions in the nourishment room, where a microwave used for preparing resident meals had grime inside and a paper towel with yellow stains stuck to the plate. The CD confirmed the microwave's use for resident food preparation and attempted to clean it. Moreover, a dented can of corn was found on the kitchen storage rack, which the CD also acknowledged and discarded. These findings indicate lapses in maintaining food safety and equipment sanitation standards.
Medical Director Absence at QA Meeting
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance committee had the required members present at their quarterly meetings. Specifically, the Medical Director did not attend the second quarter meeting in 2023. This was confirmed through a review of the Quality Assurance and Performance Sign-in Sheet and verified by the Director of Nursing (DON). This oversight had the potential to affect all residents residing at the facility, which had a census of 55 at the time of the report.
Unclean Dining Room Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the dining room, as observed during a lunch meal. On March 25, 2024, it was noted that the ceiling around the vent in the dining room was dirty. This observation was confirmed by the Director of Plant Maintenance on March 26, 2024, who acknowledged that the area needed cleaning. However, during a subsequent observation on March 27, 2024, the ceiling around the vent remained dirty, indicating that no cleaning had been performed. This deficiency has the potential to affect more than an isolated number of residents, given the facility's census of 55 residents.
Failure to Investigate Allegations of Abuse by a Resident
Penalty
Summary
The facility failed to investigate multiple allegations of abuse by a resident, identified as Resident #213, towards other residents. The incidents, documented in progress notes, included inappropriate touching, verbal abuse, physical aggression, and disruptive behavior. Despite these documented incidents, there were no corresponding entries in the facility's incident and reportables logs, indicating a lack of investigation or reporting to the required state agencies. The incidents spanned from mid-February to late March, involving various forms of abuse and aggression towards other residents, including inappropriate touching, verbal threats, and physical altercations. During an interview with the Administrator and Unit Manager, it was revealed that they were unaware of the identities of the victims and confirmed that no investigations had been conducted. The Administrator acknowledged the absence of incident reports and the failure to report these incidents to the necessary state agencies. This lack of action and oversight has the potential to affect more than a limited number of residents, given the nature and frequency of the incidents involving Resident #213.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. For multiple residents, including those with specific needs for daily 1:1 visits, the care plans did not reflect these requirements despite being listed by the Activity Director. This oversight was confirmed through staff interviews, indicating a lack of proper documentation and implementation of necessary activities for these residents. Additionally, the care plan for a resident with a diagnosis of Schizoaffective Disorder was incomplete, as it did not include this diagnosis despite recommendations from the pharmacy and notes from the Family Nurse Practitioner. Another resident's care plan failed to address the presence of bed rails, which were observed during an investigation of accident hazards. Furthermore, the care plan for a resident with a history of trauma included interventions that could not be implemented due to staffing limitations, and the cause of the trauma was not clearly documented. The facility also failed to adhere to care plan interventions related to fall prevention and tube feeding. For a resident requiring bed bolsters as a fall intervention, these were not in place as directed. Another resident's tube feeding care plan was not followed correctly, as observed during medication administration. The LPN did not secure the feeding tube, omitted required flushes, and failed to check gastric residual volume, leading to incomplete medication administration. These deficiencies highlight significant lapses in care plan implementation and adherence.
Failure to Maintain Resident Dignity and Timely Pain Management
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, as evidenced by two separate incidents involving Resident #36 and Resident #162. Resident #36's shirt became soiled with tube feeding during a medication administration observation, and the shirt was not changed before the resident was taken to the dining room to play Bingo. The following day, the resident was observed in the lounge area still wearing the soiled shirt. A Registered Nurse confirmed the need for a change of clothing, indicating a lapse in maintaining the resident's dignity and hygiene. In another incident, Resident #162 expressed pain and requested a pain pill. The surveyor informed the facility staff, and an LPN administered Tylenol to the resident in the dining room, stating that the resident's assigned nurse had requested it. The LPN later returned to administer the resident's scheduled oxycodone, indicating a delay in providing the appropriate pain management. These incidents highlight the facility's failure to uphold the residents' rights to a dignified existence and proper communication regarding their care needs.
Failure to Document Schizoaffective Disorder on MDS
Penalty
Summary
The facility failed to accurately document a diagnosis of schizoaffective disorder for a resident on their quarterly Minimum Data Set (MDS). During a record review, it was found that the Family Nurse Practitioner had recommended adding the diagnosis of schizoaffective disorder and bipolar disorder to the resident's medical record on January 5, 2024. However, while the bipolar disorder was documented, the schizoaffective disorder was not included in the resident's medical diagnosis. This discrepancy was confirmed during an interview with the Corporate Nurse, Regional Director, and Administrator, who acknowledged that the diagnosis was missing from the MDS despite being present in the quarterly assessment with an Assessment Reference Date of March 8, 2024.
Failure to Update PASRR for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident after they were diagnosed with a major mental disorder post-admission. The resident, identified as Resident #6, was initially assessed with no mental illness or mental retardation diagnosis in 2010. However, in 2017, the resident was diagnosed with major depressive disorder, and the PASRR was not updated to reflect this new diagnosis. During an interview, the Director of Nursing acknowledged the oversight, confirming that the PASRR on file was outdated and did not include the major depressive disorder diagnosis.
Omission of Schizoaffective Disorder in PASARR
Penalty
Summary
The facility failed to include a diagnosis of schizoaffective disorder in the pre-admission screening and resident review (PASARR) for one of the residents. This oversight was identified during a review of the resident's medical records, which showed that the resident had been diagnosed with schizoaffective disorder prior to admission. However, this diagnosis was not reflected in the PASARR documentation. The issue was confirmed during an interview with the Regional Director and Corporate Nurse, who acknowledged the omission in the PASARR for the resident.
Failure to Update Care Plan for Discontinued Positioning Vest
Penalty
Summary
The facility failed to revise the care plan for Resident #36 when the use of a vest for positioning was discontinued. The resident's care plan, reviewed on March 26, 2024, indicated the use of a vest for positioning while in a high back tilt wheelchair with a pommel cushion. However, observations on March 25 and March 27, 2024, revealed that the resident was in the wheelchair without the vest. Nurse Aide #64 confirmed that the vest had not been used for some time. The Director of Nursing acknowledged that the vest was replaced with a seat belt due to issues with the vest and agreed that the care plan needed updating.
Deficiencies in Neurological Assessments, Physician Notification, and Medication Administration
Penalty
Summary
The facility failed to complete neurological assessments after falls for two residents, Resident #213 and Resident #31. For Resident #213, multiple instances of incomplete neurochecks were identified following several falls. Specific checks were either not completed or were documented at incorrect times, spanning from October 2023 to March 2024. Similarly, Resident #31's neurological assessments were missing several required checks across different dates, indicating a pattern of incomplete assessments. The facility also failed to notify the physician of hyperglycemia results for Resident #8. The resident's medical record indicated a physician order to notify if blood sugar levels exceeded 350 mg/dl. However, there were numerous instances from August 2023 to March 2024 where the resident's blood sugar levels were above this threshold, yet there was no documentation to show that the physician was notified. Additionally, the facility did not administer medication per physician's order for Resident #49. The resident had an order for Trulicity, a diabetes medication, to be administered weekly. However, four out of ten doses were missed due to the medication not being available, as noted in the Electronic Medication Administration Record. The Director of Nursing confirmed the missed doses and acknowledged the difficulty in obtaining the medication.
Failure to Provide Toenail Care for Resident
Penalty
Summary
The facility failed to provide appropriate toenail care for a resident, identified as Resident #29, which was discovered through observation, family interview, staff interview, and record review. The resident's husband expressed concern about the lack of toenail care, stating that the facility staff informed him that she was not eligible for the service, and no further action was taken. Upon observation, the resident's toenails were found to be thick, yellow, and curled over the toes. There was no record of grievances or concerns regarding toenail care in the resident's records. The Licensed Practical Nurse (LPN) and Licensed Social Worker (LSW) interviews revealed that the facility had a process involving a contracted services company for toenail care, but the resident was deemed ineligible due to resource limitations. The LSW admitted to not following up after the initial referral was denied. The Director of Nursing (DON) acknowledged the condition of the resident's toenails and expressed that the staff was uncomfortable providing care due to the toenails' condition. The deficiency was identified before any corrective actions were taken.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, as evidenced by the lack of fall interventions for two residents. Resident #31's care plan included the use of bed bolsters as a fall intervention, but an observation confirmed that these bolsters were not in place. This oversight indicates a failure to adhere to the prescribed safety measures outlined in the resident's care plan. Additionally, Resident #213, who had a history of wandering and elopement, was care planned to have a wanderguard device on their leg and wheelchair. However, it was discovered that the orders for this device were not entered until after surveyor intervention, despite a previous incident where the resident had removed the device and exited the facility. The Director of Nursing confirmed the lapse in implementing the necessary safety intervention, highlighting a significant oversight in managing the resident's risk for elopement.
Deficiency in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications. During an observation of medication administration for Resident #36, it was noted that the Licensed Practical Nurse (LPN) #35 was preparing and administering medications via the resident's feeding tube. The LPN crushed several medications together and mixed them with water before administering them through the feeding tube. However, the syringe became disconnected, causing some of the medication and water to spill onto the resident's shirt. Additionally, the LPN did not administer the full amount of medication, as evidenced by particles remaining in the cup. The LPN also failed to follow the prescribed protocol for enteral feeding and medication administration. The resident's orders required flushing the feeding tube with 30 milliliters of water before and after medication administration, which was not completed. Furthermore, the LPN did not check the gastric residual volume (GRV) before administering the medications and enteral feeding, as required by the resident's care plan. The failure to check GRV could potentially lead to complications if the residual volume was too high. Moreover, the LPN administered the Isosource 1.5 feeding an hour and a half late and did not administer the Baclofen, Haloperidol, and Norco medications in their entirety. The resident's care plan also included a 120 ml water flush for hydration, which was omitted by the LPN. These actions and inactions by the LPN resulted in a deficiency in the care provided to Resident #36, as the facility did not ensure the resident received the appropriate treatment and services to prevent complications from the enteral feeding tube.
Failure to Assess Bed Rail Safety
Penalty
Summary
The facility failed to properly assess a resident for the use of bed rails, which was identified during a long-term care survey. The deficiency involved a resident who had bed rails installed on their bed without a proper safety evaluation. An observation was made of the bed rails during an investigation of accident hazards. Upon reviewing the care plan, it was found that the resident was not care planned to have bed rails. Additionally, a bed evaluation indicated the resident's interest in bed rails, but no safety evaluation was completed. Corporate RN #85 confirmed the absence of a bed rail safety evaluation and expressed unfamiliarity with what such an evaluation entails.
LPN Lacks Competency in Enteral Feeding Tube Care
Penalty
Summary
The facility failed to ensure that an LPN had the appropriate competencies to care for a resident with an enteral feeding tube. During an observation of medication administration, the LPN was seen preparing and administering medications incorrectly for a resident who was fed by enteral means. The LPN crushed several medications together and mixed them with water, but failed to administer the entire mixture, leaving medication residue in the cup. Additionally, the LPN did not flush the feeding tube with water after administering the enteral feeding and did not check the gastric volume residual (GVR) before starting the medication administration and feeding process. The facility was unable to provide evidence that the LPN's competencies regarding feeding tube care were reviewed upon her hire. The Director of Nursing was informed of the LPN's failure to flush the tube and check the GVR, but no further information was provided. The facility provided several competencies completed with the LPN, but none were related to the care and services required for residents with an enteral feeding tube.
Failure to Notify Physician of Behavioral Changes in Dementia Resident
Penalty
Summary
The facility failed to notify the physician of a change in baseline behaviors immediately for a resident diagnosed with dementia. This deficiency was identified during a long-term care survey process, where it was found that the resident had returned from a local behavioral health facility with worsening behaviors. Despite the escalation in behaviors, the physician was not informed until surveyor intervention occurred, which led to an Immediate Jeopardy situation. The resident exhibited a range of aggressive and disruptive behaviors over several days, including physical aggression, verbal threats, and attempts to elope. These behaviors were documented on behavioral monitoring task sheets, but the facility did not take the necessary step of notifying the physician promptly. The Director of Nursing confirmed during an interview that the physician was only notified after the surveyor's intervention, highlighting a lapse in the facility's protocol for managing changes in resident behavior.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, with an observed rate of 16.67%. This deficiency was identified during a medication administration observation for a resident. The Licensed Practical Nurse (LPN) involved in the administration made several errors, including failing to administer medications in their entirety and omitting required water flushes before and after medication administration. Specifically, the LPN did not administer the full doses of Baclofen, Haloperidol, and Norco, and omitted a 30 ml water flush and a 120 ml hydration flush. Additionally, the LPN administered Isosource 1.5 late and failed to check the gastric residual volume (GRV) as required. The errors were compounded by the LPN's failure to ensure that all medication was delivered through the resident's feeding tube, as evidenced by medication remaining in the cup after administration. The LPN also did not adhere to the prescribed schedule for medication administration, resulting in late administration of Isosource 1.5. These actions led to a total of seven medication errors out of 45 opportunities, contributing to the high medication error rate. The Director of Nursing was informed of these errors, but no further information was provided in the report.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents during the survey process. For one resident, the transfer form was found to be incomplete, with the transfer date incorrectly listed as a date prior to the actual transfer to an acute care facility. This discrepancy was confirmed by the Administrator and the Corporate RN. For another resident, the Physician's Scope of Orders for Treatment (POST) form was incomplete, as the signatures of the resident and the resident representative were present but lacked a date. This issue was also confirmed by the Administrator.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 72 citations issued within 25 miles in the last 12 months — 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcdowell Healthcare Center | 14.8 mi | ★★★★★ | 4 | 0 |
| Beckley Healthcare Center | 20.7 mi | ★★★★★ | 21 | 0 |
| Majestic Care Of Beckley | 22.1 mi | ★★★★★ | 7 | 0 |
| Raleigh Center | 22.7 mi | ★★★★★ | 13 | 0 |
| Pine Lodge | 23 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wyoming Healthcare Center.
100% money-back within 48 hours.
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.