Casper Mountain Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Casper, Wyoming.
- Location
- 4305 S Poplar, Casper, Wyoming 82601
- CMS Provider Number
- 535024
- Inspections on file
- 40
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 64
Citation history
Health deficiencies cited at Casper Mountain Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with multiple physical limitations who used an electric wheelchair sustained a fractured leg after getting caught in a doorway and later suffered a large bruise from bumping into a bed. Despite these incidents, no wheelchair safety assessments were completed, and the care plan was not updated with additional interventions. Staff interviews confirmed that safety assessments should have been performed for residents using power wheelchairs.
A resident with severe cognitive impairment and multiple chronic conditions was admitted at risk for pressure ulcers but did not receive timely or documented wound care after developing several pressure ulcers. Despite physician notes and nursing evaluations identifying new ulcers, necessary treatment orders and interventions were delayed, and there was no evidence of wound care prior to the resident's discharge after being sent to the emergency room.
Staff did not follow infection control protocols, as a resident's catheter bag was repeatedly placed on the floor, and the facility failed to implement its Legionella water management program. Additionally, an outbreak of gastrointestinal illness affecting 14 residents was not reported to the state licensing agency, and the interim DON was unaware of the reporting requirement.
The facility did not provide required written transfer notices or bed-hold policy information to several residents or their representatives prior to hospital transfers, and failed to notify the State LTC Ombudsman as required. Documentation of these actions was missing or incomplete, and facility policy procedures for notification and record-keeping were not followed.
Surveyors observed that a soiled fan was blowing onto a food preparation counter where food was being handled, and a rack for clean utensils was placed near dirty pipes behind the cooking area. The fan and the area behind the grill/oven were confirmed to be unclean, and the latter was not included on the cleaning schedule.
The facility did not maintain documentation showing that residents were educated on the benefits and risks of the COVID-19 vaccine or that consent or refusal forms were completed, as required by facility policy. Medical record reviews and staff interviews confirmed the absence of this documentation for several residents who were not up-to-date on vaccination.
Three cognitively intact residents were not included in the development or implementation of their person-centered care plans, as evidenced by their lack of recall of care conference invitations and absence of documentation showing their participation, despite facility policy requiring such involvement. The DON confirmed that while care conferences were held, there was no evidence of resident participation.
The facility did not ensure that advance directives were accurately formulated and documented for two residents. In one case, a resident was listed as DNR in the EMR without a signed and dated advance directive, and in another, the EMR showed full code status despite a signed form indicating no CPR. Staff confirmed discrepancies between documentation and residents' expressed wishes.
Surveyors identified that MDS assessments were not accurately completed for three residents. One resident with multiple psychiatric diagnoses was incorrectly marked as not having a serious mental illness per PASRR Level II, and another resident's functional status section (GG) was left unassessed due to lack of available staff. These deficiencies were confirmed through record review and staff interviews.
Two residents were found to be receiving psychotropic medications without proper documentation of risk-benefit analysis, gradual dose reduction attempts, or clinical rationale for continued use. The facility was unable to provide required documentation for antipsychotic and antianxiety medications, and a PRN order lacked a stop date. The DON confirmed gaps in the psychotropic medication review process and missing documentation.
A resident who declined both influenza and pneumococcal vaccines did not have documentation in the medical record showing that education on vaccine benefits and risks was provided, nor was there a record of consent or refusal, as required by facility policy. Interviews with the DON and ADON confirmed the absence of this documentation.
A resident with schizophrenia who was receiving antipsychotic, antianxiety, and antidepressant medications did not have documented monthly medication reviews or pharmacist recommendations for several months. Review of medical records and the interim DON's binder showed no evidence that the required pharmacist reviews were performed or documented, and staff confirmed the missing documentation.
The facility did not correctly issue required NOMNC and SNF ABN forms for two residents, with errors including missing reasons for non-coverage, missing estimated costs, and incorrect resident names on forms. Staff confirmed the forms were inaccurate and did not meet policy requirements for informing residents or their representatives about Medicare coverage changes and potential financial liability.
A resident with multiple non-pressure wounds did not receive consistent wound care as ordered, with missed dressing changes, lack of wound monitoring, and incomplete documentation. The wounds worsened over time, and the resident was eventually hospitalized with sepsis and cellulitis related to the untreated wounds. Staff interviews and record reviews confirmed a lack of oversight and documentation for wound care, resulting in actual harm.
Two residents received wound care from a MA-C who applied topical solutions and dressings to open wounds without performing wound assessments or measurements, and without clear evidence that such care was within the MA-C's legal scope of practice. Facility staff were unable to provide competencies for MA-Cs in wound care, and state nursing board guidance indicated that MA-Cs are not permitted to apply medications to wounds.
A medication aide-certified performed wound care for a resident with open wounds without wearing a gown, despite the resident being on enhanced barrier precautions and personal protective equipment being available. Facility policy and the infection preventionist confirmed that both gloves and gowns are required for residents with wounds.
A resident with multiple serious diagnoses was not provided their prescribed Nifedipine ER dose at bedtime following readmission, as the medication was unavailable and not administered until the next morning. Facility staff could not confirm the medication was obtained from the stat lock or properly documented, and the physician was not notified of the missed dose.
A resident's right to receive visitors was not upheld when the facility issued a no trespass order against the resident's friend after a verbal altercation with another resident. The friend was banned from visiting despite the behavior not meeting the facility's policy criteria for restricting visitation, and no less restrictive alternatives were considered.
A resident with heart failure and diabetes developed new lower extremity edema and a venous wound on the left foot, as documented in skilled nursing and wound evaluations. Despite these significant changes, there was no evidence that the resident's physician was notified, and no physician orders were present for wound care. Interviews confirmed that only the wound care team was informed, not the resident's physician.
Two residents with wounds did not receive care in accordance with physician orders or professional standards. One resident with a venous foot wound was treated by a physical therapist without physician notification or orders, and another with a surgical wound did not have physician orders or documentation for required daily dressing changes. The DON confirmed these lapses, and facility policy requiring physician involvement was not followed.
A resident with a history of falls and no reported pain was given Tramadol routinely instead of as needed (PRN) due to a transcription error. The medication was administered multiple times despite the resident having a pain level of zero, and family members expressed concern about the frequency and effects of the drug. The DON confirmed the order was incorrectly entered as routine rather than PRN.
A resident with Alzheimer's and impaired cognition had missing hearing aids for two years, with family repeatedly voicing concerns during care plan meetings. The facility failed to document or address the grievance, and staff were unaware of the issue. The facility's grievance policy was not followed, and no inventory of the resident's belongings was available.
A facility failed to implement a comprehensive care plan for a resident with moderately impaired cognition and Alzheimer's dementia. The care plan required ensuring hearing aids were in place, but records indicated the resident did not own hearing aids. Observations confirmed the resident was not wearing hearing aids, and staff interviews revealed no history of the resident using them. The administrator could not find an inventory of the resident's belongings upon admission.
The facility failed to maintain a sanitary kitchen environment, with a non-working handwashing sink and a dirty floor under the dishwasher. The cleaning schedule was not followed, and the dishwasher did not consistently reach the required sanitization temperatures. Staff were aware of these issues, but they persisted, posing a risk of contamination.
The facility failed to have a licensed administrator on-site, as the current administrator lived in a different town and was employed elsewhere. Observations showed an unlicensed administrator in training managing the facility, while the licensed administrator communicated via email and phone. The previous administrator was on leave, and the current administrator had never visited the facility.
The facility failed to maintain the Ecolab ES-4000 dishwasher at the required temperature, as observed in the kitchen. Dietary aides reported water temperatures below the recommended 120 degrees Fahrenheit, with logs showing compliance only a few times. The facility's policy and FDA guidelines emphasize the importance of maintaining specific temperatures for effective sanitization, yet the issue persisted despite awareness by maintenance and the Ecolab technician.
A facility failed to follow infection prevention guidelines during meal service in the sunflower dining area. A resident with memory impairment and dysphagia required assistance with eating, but instead, other residents attempted to help, including touching the resident's food with bare hands. The dietary staff did not intervene, and no facility staff provided the necessary assistance or cues as per the care plan. Interviews confirmed that such actions were inappropriate and against infection control policies.
A facility failed to provide a resident with the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) forms in a timely manner. The resident's Medicare Part A stay ended without evidence of these notices being issued, as confirmed by the business office manager. The facility's policy requires these forms to be used to inform residents about their rights to appeal or request expedited determinations.
A facility failed to conduct a required PASARR Level II assessment for a resident with moderate cognitive impairment and psychiatric diagnoses. The resident's PASARR Level I assessment indicated the need for a Level II determination if the stay exceeded 120 days, but no such assessment was found. The DON noted that social services were responsible for PASARR assessments, but the facility lacked social services staff and a PASARR policy.
A resident with memory impairments and multiple diagnoses required assistance with eating, as per their care plan. During a dining observation, the resident did not receive necessary help from staff, leading other residents to attempt assistance. The dietary staff and DON present did not intervene, contrary to facility policies on meal supervision and individualized care plans.
Expired medications were found in a medication cart, including an insulin Aspart flex pen and a Basaglar insulin pen without expiration dates. An RN confirmed these were for resident use and should have been dated when removed from the refrigerator. The DON stated that staff were expected to label insulin pens with an open date, which was not done. Facility policies required identifying expiration dates and disposal after 28 days, as confirmed by manufacturer guidelines.
The facility failed to provide accurate daily staff postings over a two-week period, combining LPN and MA-Cs data on one line. An observation and review confirmed this issue, and the DON acknowledged the error, stating they should have been counted separately.
The facility failed to ensure the DON was licensed by the State of Wyoming before providing nursing care. The former DON, hired without a valid license, performed nursing tasks for five residents, including assessments and documentation. Despite being aware of the licensing issue, the facility allowed the DON to provide care. The DON was later granted a license but was terminated shortly after.
Failure to Assess and Address Wheelchair Safety After Resident Injuries
Penalty
Summary
The facility failed to evaluate and address hazards and risks for a resident who was cognitively intact but had significant physical limitations, including diabetes mellitus, morbid obesity, muscle weakness, and gout. The resident required the use of an electric wheelchair for mobility. Despite these risk factors, the facility did not complete a wheelchair skill or safety assessment after the resident sustained a right leg fracture in June, which occurred when the resident's leg became caught in a courtyard doorway while using the wheelchair. Medical documentation confirmed the injury, including an orthopedic note and X-ray results showing an acute, nondisplaced oblique fracture of the distal tibial diaphysis. Additionally, the resident experienced a large bruise to the left calf after bumping into a bed with the wheelchair in October. Interviews with both the resident and the Physical and Occupational Therapy Director confirmed that no wheelchair safety assessments were conducted following either incident. The care plan only included an intervention to educate the resident on proper use of mobility devices, with no further interventions or assessments added after the injuries. An RN confirmed that safety assessments should have been completed for all residents using power wheelchairs.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and heart failure, was admitted without any existing wounds but was identified as being at risk for pressure ulcers. Despite this risk, the facility failed to implement and document appropriate wound care and monitoring. Physician notes indicated the development of an unstageable pressure ulcer on the resident's right buttocks, but there were no corresponding treatment orders or evidence of wound care in the medical record. Subsequent nursing evaluations documented additional pressure ulcers on the resident's heels, left medial calf, and coccyx, with delayed notification and action from the nursing staff and DON. Further review revealed that orders for necessary interventions, such as the use of prevalon boots and wound care, were not added until several days after the ulcers were identified. The resident's representative reported that the resident was sent to the emergency room for another issue, where concerning pressure ulcers were found, and the resident did not return to the facility. The interim DON confirmed that there was no documentation of wound care or treatment prior to the resident's discharge, indicating a failure to provide timely and appropriate pressure ulcer prevention and treatment.
Failure to Implement Infection Control, Water Management, and Outbreak Reporting
Penalty
Summary
Staff failed to implement and maintain effective infection prevention and control practices in several areas. During observation, a resident with a catheter was found with the catheter bag lying flat on the floor on two separate occasions. A CNA stated that the bed did not have a place to hang the bag, so it was placed on the floor. Both the interim DON and ADON confirmed that catheter bags should not be placed directly on the floor. Additionally, the facility did not implement its water management program for Legionella, as required by its own policy, and failed to maintain logs or review data for trends or deficiencies. An outbreak of gastrointestinal illness involving 14 residents was not reported to the state licensing agency, despite the requirement to do so. The interim DON was unaware of the reporting requirement at the time of the survey.
Failure to Provide Required Transfer Notices and Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide required written notices of transfer and information on bed-hold policies to residents and/or their representatives prior to facility-initiated hospital transfers for three out of five sampled residents. Specifically, there was no evidence that written transfer notices or bed-hold policy information were given to the residents or their representatives for multiple transfers. In some cases, the transfer notices were not signed by the facility representative, and there was no verification of receipt by the resident or responsible party. Additionally, the facility did not send copies of the transfer notices to the Office of the State Long-Term Care Ombudsman as required. Interviews with the Nursing Home Administrator confirmed the absence of documentation showing that the required notices were provided or that the Ombudsman was notified. Policy reviews indicated that the facility's procedures require written information on bed-hold practices to be provided both in advance and at the time of transfer, with documentation of attempts to notify representatives. However, these procedures were not followed, as evidenced by the lack of signed and dated copies of the notices in the residents' medical records and the failure to notify the Ombudsman.
Unsanitary Food Preparation Area and Inadequate Cleaning Practices
Penalty
Summary
The facility failed to maintain a sanitary environment in the food preparation area, as observed during surveyor visits. An upright fan, which was visibly darkened and soiled with debris, was found blowing directly onto a food preparation counter where a cutting board and knife were present. Additionally, a rack used for storing clean utensils and cookware was located directly behind the hooded gas cooking area, with visibly dirty and soiled pipes situated between the grill/oven and the storage rack. On a subsequent observation, the same unclean fan was again blowing on the food preparation area while a dietary aide was preparing individual syrup cups for residents. The dietary manager and cook confirmed the fan was not clean, and the area behind the grill/oven remained unclean. The dietary manager also confirmed that the area behind the grill/oven was not included on the cleaning schedule. No information about specific residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to maintain a system for documenting that residents were provided education regarding the benefits and potential side effects of the COVID-19 vaccination, as well as documentation of consent or refusal for the immunization. Medical record reviews for four sampled residents revealed that there was no evidence these individuals received education about the COVID-19 vaccine, nor was there a copy of a consent or declination form maintained in their records. Each of these residents was noted as not being up-to-date on the COVID-19 vaccination according to their most recent MDS assessments. Interviews with the interim DON and ADON confirmed that no further documentation was available to demonstrate compliance with the facility's own policy, which requires education and signed consent prior to vaccination. The policy also specifies that education should be provided in a language and format understood by the resident or their representative, and that documentation and reporting are overseen by the infection preventionist. Despite these requirements, the necessary documentation was not present for the residents reviewed.
Failure to Include Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to include residents in the development and implementation of their person-centered care plans for three out of five sampled residents, all of whom were assessed as cognitively intact with BIMS scores of 15 out of 15. Interviews with these residents revealed that they either did not recall being invited to care conferences or had only been invited once, despite multiple care plan revisions and assessments occurring during their stays. Medical record reviews confirmed that care conferences were either not documented as occurring at appropriate intervals or lacked evidence of resident participation. Further review of facility policy indicated that residents and/or their representatives should be included in care plan discussions at regular intervals and after significant changes, with signatures obtained to confirm participation. However, interviews with the interim DON confirmed that while care conferences were held quarterly, there was no evidence that residents participated in the planning process as required by policy. This lack of resident involvement was consistently observed across the sampled cases.
Failure to Accurately Formulate and Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly formulated and accurately documented for two residents. For one resident, the electronic medical record (EMR) indicated a do not resuscitate (DNR) status, but there was no evidence in the medical record that the resident had signed and dated an advance directive, and staff confirmed there was no documentation of the resident electing DNR status. For another resident, the EMR listed a full code status, but a CPR designation form signed and dated by the resident indicated a preference for no CPR, and staff confirmed that the EMR did not reflect the most recent election of no CPR. Review of facility policy showed requirements for inquiry and documentation of advance directives upon admission and ensuring the plan of care is consistent with documented treatment preferences, which were not followed in these cases.
Inaccurate MDS Assessments and Incomplete Functional Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident with a documented history of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and sleep terror, the MDS assessment incorrectly indicated that the resident was not considered by the state PASRR Level II process to have a serious mental illness, despite documentation to the contrary. This inaccuracy was confirmed by the MDS coordinator during an interview. Another resident's annual MDS assessment had section GG, which evaluates functional abilities and goals, marked as not assessed. The MDS coordinator stated that this section was dashed out because staff were not available at the time to perform the assessment. The RAI manual specifies that section GG is intended to capture important information about a resident's functional status, including self-care and mobility activities. These findings were based on medical record review, staff interviews, and reference to the MDS RAI manual.
Failure to Ensure Unnecessary Psychotropic Medications Are Avoided
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications for two of five residents reviewed. For one resident with a diagnosis of schizophrenia, the medical record showed ongoing prescriptions for antipsychotic and antianxiety medications, but the facility could not provide documentation of a required risk-benefit statement signed by the physician or evidence supporting a gradual dose reduction (GDR) as indicated in the assessment. Additionally, a physician order for PRN lorazepam lacked a stop date, and the interim DON confirmed that the GDR documentation could not be located and that the psychotropic medication review process was still being organized. For another resident with a diagnosis of depression, records indicated the ongoing use of an antidepressant without any attempt at GDR or documentation that a reduction was clinically contraindicated. The medication regimen review did not include a rationale for continuing the current dose, and the interim DON confirmed that no GDR was attempted and no rationale was documented. These findings demonstrate lapses in the facility's processes for monitoring and documenting the use of psychotropic medications.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to maintain a system for documenting that residents were provided education regarding the benefits and potential side effects of pneumococcal and influenza vaccines, as well as documentation of consent or refusal for immunization. In the case reviewed, a resident was admitted and subsequently declined both the influenza and pneumococcal vaccines. However, the medical record did not contain evidence that the resident was educated on the benefits and risks of these vaccines, nor was there a copy of the consent or declination form maintained in the record. Interviews with the interim DON and ADON confirmed that no further documentation was available to support that the required education or consent/refusal process had occurred. Review of the facility's policies for both influenza and pneumococcal vaccines indicated that education and documentation of consent or refusal should be provided and maintained in the resident's medical record, but this was not followed in the instance reviewed.
Failure to Document and Act on Monthly Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly drug regimen reviews, including the identification and reporting of medication irregularities, for one of five sampled residents. Medical record review and examination of the interim DON's pharmacist monthly medication review binder revealed no evidence that the pharmacist had conducted or documented monthly medication reviews or made recommendations for the months of March, April, May, or June 2025. The resident involved had a diagnosis of schizophrenia and was receiving antipsychotic, antianxiety, and antidepressant medications during the review period. Staff interviews confirmed the absence of required documentation in the resident's record and the facility's binder.
Failure to Issue Accurate Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to properly issue the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) for two out of three sampled residents. For one resident, the NOMNC form indicated the last covered day for Medicare Part A services, but the form was only signed by the social services director with a note that verbal notice was received by the resident's representative. Additionally, the SNF ABN form for this resident was found to have another resident's name at the top, and it did not include the required reason why Medicare may not pay or the estimated cost of the services. The form was also signed by the social services director with a note of verbal receipt by the representative. For another resident, the SNF ABN form indicated the last covered day for Medicare Part A services, but again failed to include the reason Medicare may not pay or the estimated cost. Interviews with the interim DON and MDS coordinator confirmed that the NOMNC and ABN forms were inaccurate. Review of facility policy showed that residents are to be informed in writing in advance when changes to their Medicare coverage occur, including the reasons for non-coverage and potential financial liability, but this process was not followed as required.
Failure to Implement and Monitor Wound Care Results in Harm
Penalty
Summary
The facility failed to implement and monitor wound care treatment as ordered for a resident with multiple non-pressure wounds on the lower extremities. The resident, who was cognitively intact and had a history of congestive heart failure, hypertension, renal insufficiency, benign prostatic hyperplasia, and encephalopathy, developed several stage 2 non-pressure ulcers on both legs and toes. Despite physician orders for specific wound care treatments, documentation showed inconsistent and incomplete implementation of these treatments, with missed dressing changes and lack of evidence for as-needed care or refusals. Wound assessments and measurements were not consistently performed or documented, and new wounds were not always identified or measured in the medical record. Wound photographs and medical record reviews revealed that the resident's wounds worsened over time, with increased size, drainage, discoloration, and additional open areas developing. The treatment administration record indicated that wound care was not performed on certain dates, and some treatments were carried out by staff not qualified to assess or measure wounds. Interviews with staff confirmed that wound care was not always documented, and there was no oversight of the wound care program within the facility. The infection preventionist acknowledged the lack of monitoring and documentation for wound care and as-needed dressing changes. The resident was eventually transferred to the hospital in poor condition, with saturated dressings and wounds covered in feces. Hospital records documented that the resident had extensive wounds with sloughed skin, erythema, and signs of infection, leading to a diagnosis of sepsis and cellulitis likely secondary to the lower extremity wounds. The facility's failure to provide consistent wound care and monitoring, as well as the lack of oversight and documentation, resulted in actual harm to the resident.
Wound Care Provided Outside Scope of Practice by MA-C
Penalty
Summary
Nursing staff failed to ensure that wound care was provided within the appropriate scope of practice for two residents. Observations showed that a Medication Assistant-Certified (MA-C) performed wound care procedures, including the application of Vashe solution and xeroform, on open wounds. The MA-C did not perform wound measurements or assessments, stating that these tasks were reserved for nurses and were only completed by the wound team on specific days. Documentation revealed that wound care treatments for one resident were performed by a MA-C, and on some scheduled dates, treatments were not performed at all. Interviews with facility staff indicated uncertainty regarding the MA-C's authority to apply topical medications to wounds. The infection preventionist/staff development coordinator was unable to provide competencies for MA-Cs performing wound care and acknowledged that MA-Cs should not apply topical medications to wounds. Review of state nursing board advisory opinions confirmed that CNA IIs and MA-Cs are not permitted to apply medications, including topical agents, to wounds, and that wound care by CNA IIs is only allowed after assessment by a provider or RN. No evidence was provided to show that the MA-C's actions were within their legal scope of practice.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During wound care for a resident with open wounds on the left shin and toe, a medication aide-certified (MA-C) performed hand hygiene and donned gloves but did not wear a gown, despite a container of personal protective equipment, including gowns, being available near the resident's bed. The infection preventionist/staff development coordinator confirmed that enhanced barrier precautions, which require both gloves and gowns, should be used for all residents with wounds, and that this resident was on such precautions. Review of the facility's policy also indicated that enhanced barrier precautions, including the use of gowns, are required for residents with wounds, regardless of known infection or colonization status.
Failure to Administer Medication as Ordered Upon Resident Readmission
Penalty
Summary
A resident with multiple complex diagnoses, including infrarenal abdominal aortic aneurysm, acute kidney failure, atherosclerosis of the renal artery, anxiety disorder, congenital renal artery stenosis, and cerebral infarction, was re-admitted to the facility from the hospital. Upon review, it was found that the resident did not receive their prescribed dose of Nifedipine ER 30 mg at bedtime as ordered by the physician. The medication was not available upon the resident's return, and the dose was not administered until the following morning, as confirmed by the resident, their representative, and the physician's note. The Medication Administration Record (MAR) indicated the medication was not provided at the scheduled time, and there was no documentation to confirm the medication was obtained from the stat lock or administered as required. Interviews with facility staff revealed that the expectation was to obtain unavailable medications either from a local pharmacy or from the stat lock if the primary pharmacy could not supply them in time. However, the DON was unable to provide evidence that the medication was accessed from the stat lock or given to the resident. The physician was not notified of the missed dose, and the facility's policy required medications to be administered as ordered and documented in the MAR. The failure to provide the medication as prescribed and to document its administration resulted in the identified deficiency.
Resident's Visitation Rights Restricted Without Just Cause
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing when a no trespass order was issued against the resident's friend, preventing further visits. The incident began when the resident's friend witnessed an altercation in which another resident accused the resident of hitting them. The friend, who observed the event, verbally defended the resident and addressed the other resident directly. Following this, the facility reported the incident, noting that the visitor had verbally expressed frustration but had left before law enforcement arrived. The police later informed the friend that they were no longer permitted to visit the facility. Interviews with the administrator revealed that the decision to issue the no trespass order was based on the friend's disrespectful behavior, which did not rise to the level of verbal abuse or a pattern of problematic conduct. The administrator also confirmed that no less restrictive measures, such as supervised or limited visitation, were attempted prior to the ban. Review of facility policy indicated that visitation restrictions are only to be applied in cases of abuse, exploitation, or coercion, and not for disrespectful behavior. The policy did not support the action taken in this case.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's physician of significant changes in the resident's condition. The resident, who had a history of heart failure and diabetes mellitus, was admitted without any wounds or edema. However, subsequent skilled nursing evaluations documented the development of pitting edema in both lower legs over several days, and a wound evaluation later identified a venous wound on the left foot that required treatment with Unna boots. Despite these new findings, there was no evidence in the medical record that the resident's physician was notified about the new onset of edema or the venous wound. Interviews with a family member and the DON confirmed that the physician was not informed of these changes. The family member was unaware of any physician notification and stated that only the wound care team was informed. The DON clarified that while a physician rounded with the wound care team, it was not the resident's primary physician, and there was uncertainty about whether communication occurred between physicians. Additionally, there were no physician orders for the wound care provided, and the facility could not provide documentation of physician notification regarding the resident's new conditions.
Failure to Provide Wound Care per Physician Orders and Standards
Penalty
Summary
The facility failed to provide wound care in accordance with physician orders and professional standards for two residents with non-pressure-related wounds. For one resident with heart failure and diabetes, a venous wound developed on the left foot and was treated by a physical therapist with Unna boots, Coban, and later with wound cleanser, zinc, and bordered gauze. There was no evidence in the medical record that the resident's physician was notified of the wound or that physician orders were obtained for the wound care. The family was not aware of physician notification, and the DON confirmed that wound care was recommended by the physical therapist without physician involvement or orders. For another resident with a surgical wound from a right thumb amputation, the orthopedic follow-up recommended daily dressing changes. However, there were no physician orders for these dressing changes, nor was there documentation that the dressing changes were completed. The DON confirmed that the facility had not seen the orthopedic note until later and that the resident occasionally requested a band-aid from staff. The facility's policy required wound treatments to be provided per physician orders and for the physician to be notified in the absence of such orders, but this was not followed in these cases.
Medication Administration Error: Unnecessary Drug Use Due to Transcription Mistake
Penalty
Summary
A deficiency occurred when a resident was administered Tramadol without adequate indication for its use. The resident, who had a history of falls and unspecified pain but did not report pain during the assessment period, was admitted with an order for Tramadol 50 mg every 6 hours as needed (PRN) for pain. However, the order was incorrectly transcribed as a routine order for every 6 hours, rather than PRN, and remained in place for approximately 11 days. During this period, the resident received Tramadol seven times when their pain level was documented as zero. Family members noticed the resident appeared 'out of it' and requested that Tramadol not be given as frequently, preferring scheduled Tylenol Arthritis and Tramadol only at bedtime. The DON later confirmed the transcription error regarding the medication order.
Failure to Address Missing Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident with moderately impaired cognition and Alzheimer's dementia. The resident's family repeatedly voiced concerns about missing hearing aids during care plan meetings over a two-year period, but no grievance form was filled out, and no action was taken to locate or replace the hearing aids. The facility's grievance logs showed no documentation related to the missing hearing aids, and the care plan intervention to ensure hearing aids were in place was not followed. Interviews with the resident's representative revealed that the family was unaware of the need to fill out a grievance form and had verbally informed staff of the issue multiple times. The administrator and social services director were unaware of the missing hearing aids, and the protocol for handling grievances was not followed. Additionally, there was no inventory of the resident's belongings from admission, and staff interviews indicated that the resident had not been seen wearing hearing aids for several years. The facility's policy required staff to record grievances and take immediate action, but this was not done in this case.
Failure to Implement Comprehensive Care Plan for Resident with Hearing Impairment
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with moderately impaired cognition and Alzheimer's dementia. The resident's quarterly MDS assessment indicated a BIMS score of 10 out of 15, and the social services assessment noted highly impaired hearing. The care plan, last updated on 1/12/25, included an intervention to ensure hearing aids were in place due to difficulty hearing related to advanced age. However, medical records and ADL tasks from 12/16/24 to 1/14/24 indicated the resident did not own hearing aids. An observation on 1/15/25 confirmed the resident was not wearing hearing aids. A medication aide, who had provided care to the resident for six years, stated he had never seen the resident wear hearing aids, and the administrator could not find an inventory of the resident's belongings upon admission, confirming the resident had not been wearing hearing aids.
Sanitation and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as observed during a survey. A non-working handwashing sink in the dishwashing room had a disconnected drain pipe, leading to water being collected in a bucket underneath. The floor under the dishwasher was found to be dirty with grime, food particles, and hard water build-up. The cleaning schedule posted in the kitchen lacked initials indicating cleaning had been performed since a specific date. Interviews with kitchen staff revealed ongoing issues with broken faucets and a lack of adherence to the cleaning schedule. The facility's dishwasher was not operating at the required temperatures for effective sanitization. Observations showed that the Ecolab ES-4000 dishwasher's water temperature started at 110 degrees Fahrenheit and only occasionally reached the required 120 degrees Fahrenheit after multiple runs. The dishwasher temperature logs for March and May 2024 indicated that the wash water temperature reached the required level only a few times out of numerous opportunities. Interviews with dietary aides confirmed awareness of the low temperatures, and it was noted that both facility maintenance staff and an Ecolab technician were informed of the issue. The facility's policies and procedures, as well as the 2022 FDA Food Code, emphasize the importance of maintaining proper plumbing and dishwasher temperatures to prevent potential health hazards. The facility's failure to adhere to these standards, as evidenced by the broken plumbing and inadequate dishwasher temperatures, poses a risk of contamination and does not comply with professional standards for food safety and sanitation.
Facility Lacks On-Site Licensed Administrator
Penalty
Summary
The facility failed to ensure that a licensed administrator was responsible for the management of the facility. The census was 74. The facility administrator, interviewed on June 13, 2024, confirmed that she did not reside in the same town as the facility and communicated with the facility via email and phone calls. She was unable to work on-premise due to employment with another agency in her town and had never visited the facility. Observations from June 10 to June 13, 2024, showed that the identified facility administrator was not present on the premises during the survey. Instead, an unlicensed administrator in training occupied the administrator's office and performed management functions. Interviews with the Director of Nursing (DON) and the administrator in training on June 10, 2024, revealed that the facility administrator did not work on-site and had weekly calls with the facility. The Chief Operating Officer confirmed on June 13, 2024, that the previous administrator went on leave on May 20, 2024, and was expected to return on June 24, 2024. The current licensed administrator was employed at another agency in her town.
Failure to Maintain Dishwasher Temperature
Penalty
Summary
The facility failed to ensure that essential equipment, specifically the Ecolab ES-4000 chemical sanitizing low-temperature dishwasher, was in safe operating condition in the kitchen. Observations and interviews revealed that the dishwasher's water temperature was consistently below the manufacturer's recommended minimum of 120 degrees Fahrenheit. On multiple occasions, dietary aides reported that the water temperature started at 110 degrees Fahrenheit and only occasionally reached 120 degrees Fahrenheit after several runs. The facility's dishwasher temperature logs for March and May 2024 showed that the required temperature was met only a few times out of numerous opportunities. The facility's dishwasher temperature policy mandates adherence to the manufacturer's instructions, which specify a wash temperature of 120 degrees Fahrenheit. However, the facility did not consistently meet this requirement. The 2022 FDA Food Code emphasizes the importance of maintaining specific parameters, such as temperature, to ensure effective sanitization. The report indicates that both facility maintenance and the Ecolab technician were aware of the low water temperatures, yet the issue persisted, leading to a deficiency in maintaining essential equipment in safe operating condition.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to infection prevention guidelines during meal service in the sunflower dining area. Resident #36, who has short-term and long-term memory impairment, diabetes mellitus, non-Alzheimer's dementia, and dysphagia, required assistance with eating. During an observation, a dietary staff member was seen passing meal trays while an unidentified resident attempted to reposition Resident #36 to a table. Resident #36 began piling items on their plate and was not consuming any food. Other residents, #55 and #61, attempted to provide verbal cues and physical assistance to Resident #36, including picking up food with bare hands and trying to help them eat and drink. The dietary staff member did not intervene, and no facility staff provided the necessary assistance or cues as outlined in the resident's care plan. Interviews with the Director of Nursing (DON) and the infection preventionist confirmed that staff should follow the care plan for eating assistance and that it is inappropriate for residents to touch another resident's food. The infection preventionist highlighted the risk of contamination from residents' hands. The facility's policy on Activities of Daily Living states that residents unable to carry out daily activities should receive necessary services to maintain good nutrition and hygiene, which was not adhered to in this instance.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the Notice of Medicare Provider Non-Coverage (NOMNC) and the Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) forms to a resident or their representative in a timely manner. This deficiency was identified during a review of beneficiary protection notice information, staff interviews, and policy and procedure reviews. Specifically, a resident with a Medicare Part A stay beginning on December 29, 2023, and ending on March 12, 2024, did not have evidence of receiving the required SNF ABN or NOMNC forms at the end of their Part A services. An interview with the business office manager confirmed the notices should have been issued, but there was no evidence to support that they were provided. The facility's policy on Advance Beneficiary Notice, reviewed on June 13, 2024, mandates the use of the SNF ABN form CMS-10055 for Part A items and services and the issuance of the NOMNC form CMS-10123 when Medicare-covered services are ending. This policy aims to inform residents about how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). However, the facility did not adhere to this policy for the resident in question.
Failure to Conduct PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level II was conducted for a resident with a qualifying diagnosis. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, was diagnosed with anxiety disorder and post-traumatic stress disorder. A PASARR Level I assessment had been completed, indicating the need for a Level II determination if the resident's stay exceeded 120 days. However, there was no evidence of a PASARR Level II assessment in the resident's medical record. Interviews with the Director of Nursing (DON) revealed that social services were responsible for PASARR assessments, but the facility lacked social services staff at the time and did not have a PASARR policy in place.
Failure to Assist Resident with Dining Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically during dining, for a resident with memory impairments and multiple diagnoses, including diabetes mellitus, non-Alzheimer's dementia, and dysphagia. The resident required set-up or clean-up assistance with eating, as outlined in their care plan. However, during an observation in the dining room, the resident was seen piling items on their plate and banging the table without consuming any food. Other residents attempted to assist by providing verbal cues and physically helping the resident to eat and drink, but no facility staff intervened to provide the required assistance or cues. The dietary staff member present did not offer any help, and the Director of Nursing (DON), who was also in the dining room, did not provide assistance or cues to the resident. Interviews with the DON and the infection preventionist confirmed that it was inappropriate for other residents to assist with eating and that staff should follow the care plan for eating assistance. The facility's policies on activities of daily living and meal supervision emphasized the need for individualized care plans and adequate supervision during mealtime, which were not adhered to in this instance.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that expired medications were not available for use in one of the three medication storage units, specifically the 200-hall medication cart. During an observation, it was found that an insulin Aspart flex pen and a Basaglar insulin pen were present without expiration dates. An interview with an RN confirmed that these medications were intended for resident use and should have been dated when removed from the refrigerator. The Director of Nursing (DON) stated that it was expected for staff to label insulin pens with an open date, and acknowledged that the observed pens were not labeled with an open or expiration date. The facility's policy on medication administration required identifying expiration dates and notifying the nurse manager if expired. Additionally, the insulin pen policy mandated clear labeling with the resident's name, physician's name, date dispensed, and expiration date, and specified disposal after 28 days or per manufacturer's recommendation. Manufacturer guidelines confirmed that both insulin types should be discarded after 28 days.
Inaccurate Daily Staff Postings
Penalty
Summary
The facility failed to provide accurate data on the daily staff postings for a two-week look-back period. On 6/10/24, an observation of the posted nurse staffing showed that the census was 74, and the staffing data for LPNs and MA-Cs was combined on one line of the posting. A review of the daily staff postings from 6/11/24 confirmed that the LPN and MA-Cs staffing data continued to be combined on one line. An interview with the Director of Nursing (DON) on 6/12/24 confirmed that the daily staff postings incorrectly combined the LPN/LVNs and MA-Cs, and she acknowledged that they should have been counted separately.
Unlicensed Nursing Care Provided by DON
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) was licensed by the State of Wyoming before providing nursing care to residents. The former DON was hired without a valid Wyoming nursing license and was supposed to perform only administrative duties until obtaining the license. However, the former DON engaged in nursing care activities, including completing assessments and documentation for five residents. These activities included completing an Abnormal Involuntary Movement Scale assessment, an Alert Charting Note, a Braden Scale assessment, a medication reconciliation form, and adding medications to the electronic medical record. The facility was aware of the licensing issue, as confirmed by an interview with the chief of operations, who stated that the former DON was only to perform administrative tasks until licensed. Despite this, the former DON provided nursing care without the necessary licensure. The former DON was eventually granted a Wyoming nursing license but was terminated shortly after. Interviews with the human resource director and the nursing home administrator confirmed the timeline of events and the provision of nursing care without a license.
Latest citations in Wyoming
A resident with severe cognitive impairment and dementia had facility-managed trust funds used to purchase three Meta virtual reality headsets via Amazon. The corresponding debit was recorded in the trust account, but the devices were later found stored, largely unopened, in the activities room, with the activities director unaware of their ownership or use and unable to operate them. The resident’s representative was not informed of the purchase and believed the resident could not use such devices, while the NHA stated the items were bought as part of a Medicaid spend-down for the resident and possibly friends.
A resident with mild cognitive impairment, dementia, and depression developed UTI symptoms and was started on Keflex after a positive urine culture, with multiple notes documenting the infection and antibiotic treatment. The resident later told their representative they were taking medication for an infection, leading the representative to contact the facility for information. Facility records showed the representative was only notified days later when a follow-up urine sample was collected to confirm clearance of the infection, with no documentation of notification at the onset of the UTI or initiation of treatment. The DON confirmed the absence of documentation, despite a facility policy requiring immediate notification of the resident, physician, and resident representative when a new treatment is started.
A resident who was cognitively intact but dependent for transfers and required a full body mechanical lift was being moved from bed to a recliner by two aides when a sling shoulder strap detached from the lift, causing a fall. Staff and witness statements confirmed that the lift in use lacked safety clips on the spreader bar, despite manufacturer instructions requiring safety clips to be present and properly used. The DON acknowledged that safety clips had been removed from the lifts because they were viewed as ineffective. The resident sustained a cervical fracture and subsequently went into cardiac arrest with death pronounced the same day, and the situation was determined to be immediate jeopardy.
Surveyors found that staff failed to follow infection prevention practices for urinal use and maintenance for three residents. One resident with severe cognitive impairment and multiple comorbidities had a urinal containing urine with visible discoloration and dried residue that was not dated. Two urinals for another resident were still in place more than a month after the date written on them, and a third resident’s urinal showed staining and was not labeled with a date. CNAs reported that urinals were typically changed monthly and as needed, while an LPN and the infection preventionist stated that soiled urinals should be discarded and replaced, and that urinals should be labeled and replaced at least monthly. The DON confirmed urinals should be replaced when visibly soiled and acknowledged there were no written facility policies governing urinal use.
A resident with severe cognitive impairment and a history of hip fracture, stroke, anxiety, and depression had a care plan indicating a preference for twice-weekly baths and a need for maximum assist with bathing. Bathing records showed the resident initially received showers twice weekly, but the frequency was later reduced to once weekly after the resident moved to another unit, without documented reassessment of bathing preferences. The administrator acknowledged that preferences should have been reassessed after the move, while bath aides reported that bathing schedules are generally maintained and that they would ask new residents about their preferences. The current bathing schedule and medical record confirmed the resident was only scheduled for weekly showers, with no documented reevaluation or change in the care plan to support the reduced frequency.
The facility failed to prevent accident hazards and provide adequate supervision related to hot beverage service. A resident with moderate cognitive impairment, stroke, hemiplegia, contractures, and dysphagia, who was care-planned to receive hot liquids only in a Kennedy cup and at non-scalding temperatures, was instead given hot coffee in a Styrofoam cup without a lid and left unsupervised, resulting in burns to the thighs requiring ED treatment. Surveyors also observed multiple residents independently dispensing very hot coffee or water directly from a machine into open cups, then ambulating with walkers while carrying these beverages, sometimes spilling them. Staff interviews confirmed that machine water was not supposed to be served directly to residents, that dining room staffing was often below the intended level, and that there were no clear interventions to prevent residents from independently accessing the hot beverage machine, leading to an immediate jeopardy finding.
Two cognitively impaired roommates, one with severely impaired memory and verbal behavioral symptoms and the other with moderate cognitive impairment, dementia, and anxiety, became involved in a physical altercation after a CNA briefly left their shared room. Staff heard loud noises and found one resident with a raised fist and the other holding a Bible raised toward the first, with both admitting they had been fighting and one stating the other was in the way. The injured resident was found to have blood, scratches, and two small abrasions on the left cheek, while the other had no injuries, demonstrating a failure to protect a resident from physical abuse by another resident.
A resident was documented by nursing staff as calmly walking in the dining room, then suddenly punching another seated resident in the face, after which the aggressor was removed and placed on 1:1 supervision and the victim was assessed, showing only a pre-existing red cheek mark without swelling or pain. However, the facility’s internal incident report later characterized the event as a face "push" with no injury or distress, and the allegation was not reported to the state survey agency until more than 24 hours later. The administrator acknowledged that the original allegation of a punch was not accurately reported and that the facility reported the investigation’s conclusion instead of the actual allegation, contrary to the facility’s abuse reporting policy requiring prompt reporting of all abuse allegations.
A cognitively intact resident with stable mood and no recent behavioral issues intervened when another resident, who had bipolar disorder and a recent history of increased aggression, inappropriate sexual behaviors, refusal of care, and delusions following hospitalization for aspiration pneumonia, was teasing another resident in the dining room. In response, the behaviorally escalated resident directed profane and threatening language at the intervening resident, causing visible distress and a verbal exchange before staff arrived and the aggressive resident left the area. Surveyors found that the facility failed to protect the resident’s right to be free from verbal abuse by another resident.
Surveyors found unsanitary kitchen conditions and inadequate food safety monitoring, including a grimy Traulsen refrigerator with a sticky handle, a soap dispenser with dark buildup, and an ice scoop stored on top of the ice machine near hair nets. An undated, unlabeled package of ham and a partially uncovered, undated bowl of crushed vanilla wafers were observed in food storage areas, and the walk-in refrigerator thermostat showed no temperature. No temperature logs were available for the walk-in refrigerator, freezer, or the Ecolab XL dish machine, despite manufacturer requirements for specific wash and sanitizing temperatures and facility policies mandating daily logging of cooler, freezer, and dishwasher temperatures, as well as labeling and dating of refrigerated foods and maintaining clean, sanitary food service areas.
Misappropriation of Resident Trust Funds for Unused Virtual Reality Devices
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when items were purchased with the resident’s trust account funds and not used for the resident’s benefit. The resident had severe cognitive impairment, with a BIMS score of 3/15 and diagnoses including dementia, non‑traumatic brain dysfunction, and Meniere’s disease, and the facility managed the resident’s funds through a trust account. Documentation showed that an Amazon order was placed for this resident that included three Meta virtual reality headsets at $399.99 each, and the resident’s trust account transaction history reflected a corresponding debit of $1,878.78 for Amazon purchases. Attempts to interview the resident were unsuccessful due to cognitive debilities. Surveyor observation found three Meta virtual reality headsets in their original boxes, one opened, stored in the activities storage room near the main dining room. The activities director stated she did not know who the devices belonged to, that they had been stored in the closet since February of the prior year, that the devices required internet access, and that she did not know how to use them. The resident’s responsible party reported having no knowledge of the Meta purchase and did not believe the resident would have been capable of operating the devices. The NHA stated that the resident was obligated to spend down the trust account as a Medicaid requirement and that three Meta virtual reality headsets were ordered for the resident and possibly some friends to use.
Failure to Notify Resident Representative of UTI and New Antibiotic Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in condition when the resident developed a urinary tract infection (UTI) and was started on antibiotic therapy. The resident had a diagnosis of non-Alzheimer’s dementia and depression, with an annual MDS showing a BIMS score of 11/15 (mild cognitive impairment), no delirium, behaviors, or hallucinations, and independence with personal, oral, and toileting hygiene, and continence of bowel and bladder. On 2/2/26 at 8:02 AM, a health status note documented the resident’s complaints of dysuria, urinary urgency, and frequency, and that a urinalysis was collected. Later that day at 10:38 PM, another health status note documented that the resident was being monitored on Keflex (cephalexin) day 1 of 7 for a UTI with no adverse reaction. On 2/3/26 at 11:45 AM, a health status note documented the resident was on Keflex day 2 of 7 for a UTI, was up out of bed, alert to staff, and had no complaints of nausea, vomiting, diarrhea, skin reactions, or discomfort. An infection note on 2/3/26 at 1:30 PM documented a confirmed UTI diagnosis based on dysuria, increased urgency/frequency, and a positive urine culture, with a 7-day course of cephalexin ordered and instructions for good hygiene and fluids. The resident’s representative reported in a telephone interview that she learned of the infection only after the resident told her they were taking medication for an infection, prompting her to contact the facility for information. Review of communication notes showed the representative was notified on 2/12/26 that a urine sample was being collected to ensure the infection had cleared, but there was no documentation that the representative had been notified at the onset of the UTI or when treatment was initiated. The DON confirmed there was no documentation of notification, despite the facility’s policy requiring immediate notification of the resident, physician, and resident representative when there is a need to commence a new form of treatment.
Failure to Use Required Safety Clips on Mechanical Lift Resulting in Resident Fall and Cervical Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe staff practices and safe working conditions when using a full body mechanical lift for a resident who was dependent for transfers. The resident had a BIMS score of 15/15, indicating intact cognition, and medical diagnoses including morbid obesity, heart failure, and renal insufficiency, and required a full body mechanical lift for transfers. On the day of the incident, the resident was being transferred from bed to a recliner by two aides using a full body mechanical lift when the left shoulder strap of the sling came loose from the lift, causing the resident to fall to the floor. Witness documentation and staff interviews indicated the resident was found face down on the floor with legs over one leg of the lift, with all but one sling strap still attached. The incident report concluded that the resident had a tendency to shift weight and reposition while in the sling and that the sling strap likely came up on one side and then came off the lift. Further investigation showed that the mechanical lift in use at the time of the fall did not have safety clips on the spreader bar, as confirmed by both aides involved in the transfer and by an RN who responded to the incident. The RN identified the specific model used and confirmed that safety clips were not present at the time of the fall. A laminated Quick Reference Guide attached to the same model of lift, and the manufacturer’s Quick Reference Guide provided by the DON, both instructed staff to ensure safety clips on the spreader bar are in position after the sling is applied and to check that safety clips are present and used properly. The DON reported that safety clips had been removed at some point because they would come off and were considered ineffective. Based on the failure to follow manufacturer instructions for use of safety clips on the mechanical lift, the resident fell from the lift and sustained a mildly displaced fracture of the left C2 transverse process with extension into the C2 vertebral body, and later went into cardiac arrest with death pronounced the same day. This failure was determined to constitute immediate jeopardy.
Failure to Implement Proper Urinal Cleaning and Replacement Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the use and maintenance of urinals for three sampled residents. One resident with severe cognitive impairment, cancer, depression, non-Alzheimer’s dementia, lower extremity impairment, who was wheelchair bound and required substantial to maximal assistance with toileting hygiene, was observed with a urinal hanging from a trash can next to a recliner that contained approximately 100 milliliters of amber-colored urine. The urinal showed dark blue and black discoloration inside and a dried yellow substance around the opening, and it was not labeled with a date. A CNA stated that residents’ urinals were emptied every two hours and replaced monthly, and later confirmed that this urinal was not dated and appeared discolored and soiled. Additional observations showed two empty urinals dated more than a month earlier hanging from a trash can next to another resident’s bed, with a CNA confirming they had not been replaced after one month of use. Another resident’s urinal was observed hanging from a nightstand, empty but with yellow, amber, and dark blue staining inside, and it was not dated; a CNA confirmed the urinal appeared soiled and undated and reported that urinals were changed monthly and as needed. An LPN stated staff were expected to discard soiled urinals and replace them when they appeared soiled. The infection preventionist reported that staff were expected to label urinals and replace them at least monthly or when visibly soiled, and the DON confirmed urinals should have been replaced when visibly soiled and acknowledged there were no facility policies regarding urinals.
Failure to Maintain Resident’s Preferred Bathing Frequency After Unit Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s activities of daily living, specifically bathing, according to the resident’s assessed needs and stated preferences. A quarterly MDS dated 1/23/26 for resident #11 showed a BIMS score of 3/15, indicating severe cognitive impairment, and diagnoses including a history of hip fracture, stroke, anxiety, and depression. The care plan dated 10/24/25 documented that the resident preferred bathing twice a week and required maximum assistance with bathing and showering. Review of the bathing record from 12/10/25 through 1/6/25 showed the resident received showers twice weekly until 1/14/26, when the frequency was reduced to once weekly. The administrator stated on 3/12/26 that the resident had moved from another unit on 12/30/25 and that shower preferences should have been reassessed and had changed, but no evidence of such reassessment was found. Bath aide interviews indicated that bathing schedules were expected to be maintained when residents moved units and that staff would typically ask new residents about their bathing preferences. The current bathing schedule and medical record confirmed the resident was scheduled for and receiving only weekly showers, with no documented reevaluation of preferences or change in the bathing schedule.
Inadequate Supervision and Unsafe Hot Beverage Practices Leading to Burns and Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and appropriate devices to prevent accidents, particularly related to hot beverages. One resident with moderate cognitive impairment, a history of stroke, hemiplegia, hemiparesis with hand contractures, and dysphagia had a care plan requiring use of a Kennedy cup for all hot beverages and that food and fluids be served at non-scalding temperatures. Despite these interventions, the resident was given hot coffee in a Styrofoam cup without a lid during a period when the facility was using disposable dinnerware due to an influenza outbreak. The CNA who provided the coffee left the room to care for another resident, and the resident subsequently spilled the coffee into their lap, resulting in burns to the thighs that required ED evaluation and treatment. Surveyors identified additional concerns in the dining room where multiple residents independently accessed hot beverages from a coffee machine and water spout without lids or assistance. One resident independently obtained coffee in an open cup, placed it on a walker seat, and ambulated, causing the coffee to spill. Other residents independently obtained hot water from the coffee machine water spout into open cups and walked back to their tables while simultaneously pushing walkers, sometimes spilling coffee on themselves and tables, though without documented injury in those instances. Observations showed that residents were routinely allowed to obtain hot beverages on their own, often in open cups without lids, while using walkers. Further observations and staff interviews revealed that the water from the coffee machine measured 176.7°F and later 168.7°F, and dietary staff stated that water from the coffee machine was never supposed to be given directly to residents and that coffee and water temperatures were checked in the kitchen and not to be served directly from the machine. A CNA reported that residents were allowed to independently obtain beverages, that there was supposed to be two aides in the dining room prior to meals but usually only one was present, and that she was unaware of any interventions to prevent residents from filling cups from the coffee machine. She also stated that specialty adaptive items were identified on meal trays, but beverages were usually provided before trays came out, contributing to residents independently accessing hot beverages. These combined actions and inactions led to the determination of immediate jeopardy related to accident hazards and inadequate supervision.
Failure to Prevent Resident-on-Resident Physical Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when two cognitively impaired roommates engaged in a physical altercation. One resident had severely impaired memory, verbal behavioral symptoms directed toward others, and a diagnosis of non-Alzheimer’s dementia. The roommate had moderate cognitive impairment with a BIMS score of 10/15 and diagnoses including dementia and anxiety. On the day of the incident, a CNA had taken the first resident into the shared room to watch television while the roommate was on their side of the room looking through personal belongings. After the CNA briefly left for the nurses’ station, loud noises were heard coming from the room. When the CNA returned, both residents were next to each other, with the first resident holding a fist up and the roommate holding a Bible raised toward the first resident. Both residents stated they had been fighting, and the roommate said the other was “in the way.” The CNA and RN observed blood and scratches on the first resident’s face, and assessment revealed two small abrasions to the left cheek. The roommate had no injuries. Staff interviews confirmed that the altercation occurred between the two roommates and that the injured resident required cleaning of the facial abrasion. This sequence of events constituted a failure to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Accurately and Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to accurately and timely report an allegation of resident-to-resident abuse involving one sampled resident. A nurse’s progress note documented that a resident was walking calmly in the dining room, approached another seated resident, and, without any cue, drew back a clenched fist and punched the seated resident in the face. The aggressor was immediately redirected, removed from the situation, and placed on one-to-one supervision, and was noted to have no recollection of the event. A separate allegation form for the involved resident who was struck stated that this resident had been sitting in the dining room when another resident punched them in the face, that they had done nothing to incur the event, and that they did not recall the situation moments later. The resident who was struck was assessed and found to have a red mark on the cheek that appeared pre-existing, with no swelling or pain noted. A facility-reported incident created later the same day described the event differently, stating that one resident walked near another and “pushed” the other resident’s face, with both residents separated and redirected and no injury or distress noted. This incident was not reported to the state survey agency until the following day at 5:45 PM, approximately 24 hours and 45 minutes after the alleged incident. The administrator confirmed that the allegation that one resident punched another was not accurately reported, explaining that the facility’s investigation concluded the action was a push, and that the facility reported the results of the investigation as the allegation rather than reporting the original allegation itself. The facility’s abuse reporting policy required the Executive Director or designee to report all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property immediately but not later than 2 hours when the events involve abuse or result in serious bodily injury.
Failure to Protect Resident From Verbal Abuse During Dining Room Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by another resident during a dining room incident. One resident, who was cognitively intact with a BIMS score of 15, a low mood score, and no documented behaviors or refusal of care during the look-back period, intervened when another resident was teasing an unidentified resident. The second resident, who also had a BIMS score of 15, a mood score of 4, and a diagnosis of bipolar disorder, had recently experienced aspiration pneumonia requiring hospitalization and readmission, and subsequently exhibited increased aggressive and inappropriate sexual behaviors toward staff, refusal of care, and delusional behavior over several days. On the date of the incident, when the cognitively intact resident asked the behaviorally escalated resident to stop teasing another resident, the latter responded by calling the resident a “fat bitch,” telling the resident to “shut the fuck up,” and threatening to “knock [their] fucking teeth out.” The verbally abused resident became visibly upset and responded by challenging the other resident to hit them. The altercation occurred in the dining area before additional staff arrived, at which point the aggressive resident left and returned to their room. The survey determined that, in this event, the facility failed to protect the resident’s right to be free from verbal abuse by another resident.
Unsanitary Kitchen Conditions and Lack of Temperature Monitoring for Food and Dishwashing Equipment
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions and inadequate food safety practices in the facility’s kitchen. Observation of the kitchen preparation area showed the Traulsen refrigerator had visible grime and dried food particles on its surface and a sticky handle. The handwashing sink’s soap dispenser had a dark, reddish buildup on the pump, and the ice machine scoop was stored on top of the machine next to packaged hair nets. In the food storage areas, surveyors observed an undated, unlabeled package of ham in the Traulsen refrigerator, and a partially uncovered, undated bowl of crushed vanilla wafers on a bottom shelf of the walk-in pantry. The walk-in refrigerator did not display a temperature on its thermostat, and there were no visible temperature logs for the walk-in refrigerator or freezer. Further review and interviews showed additional failures in monitoring and documentation of required temperatures. There were no temperature logs available for the Ecolab XL dishwashing machine, despite manufacturer’s instructions specifying minimum operating temperatures of 150°F for the wash cycle and 180°F for the sanitizing rinse. The assistant dietary manager confirmed there were no dish machine temperature logs, acknowledged the ham was undated and should have been labeled with the food name and open date, and stated the ice scoop was washed after each use and placed on top of the dish machine. He was unsure about the buildup on the soap dispenser and incorrectly reported that the walk-in refrigerator temperature should have been 20–30 degrees. He believed the dietary manager kept the walk-in logs, but the director of maintenance confirmed there were no temperature logs for the walk-in refrigerator or freezer and that the outside refrigerator temperature reading was incorrect. These practices were inconsistent with facility policies requiring daily logging of cooler/freezer and dishwasher temperatures, maintaining specific temperature ranges for refrigerated and frozen storage, and ensuring refrigerated food is labeled, dated, and monitored, as well as policies requiring all food areas to be kept clean and sanitary.
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