Granite Rehabilitation And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheyenne, Wyoming.
- Location
- 3128 Boxelder Dr, Cheyenne, Wyoming 82001
- CMS Provider Number
- 535013
- Inspections on file
- 39
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Granite Rehabilitation And Wellness during CMS and state inspections, most recent first.
A resident with severe dementia and behavioral symptoms, including wandering and aggression, did not receive appropriate behavioral health care and services. The care plan lacked comprehensive, individualized interventions, and staff primarily relied on redirection and medication without documented non-pharmacological strategies. The resident's escalating behaviors led to a physical assault on staff and another resident, resulting in police involvement and arrest.
A resident with severe cognitive impairment and multiple health conditions became physically aggressive, assaulted an LPN, and was arrested for aggravated assault. The facility issued an immediate discharge notice and transferred the resident to a detention center but failed to ensure the receiving facility could meet the resident's needs or to communicate required information as outlined in policy. Documentation from a healthcare provider justifying the discharge was also lacking.
The facility failed to provide adequate nursing staff, leading to long wait times for resident assistance and missed care activities like showers. Observations and interviews revealed that staffing levels were below required levels, with only two CNAs available for a large number of residents. Payroll data showed low weekend staffing and a one-star staff rating, while Hospitality Aides were incorrectly counted as nursing staff despite being unable to provide direct care.
A facility failed to identify and monitor target symptoms for a resident receiving psychotropic medications, despite the resident being cognitively intact and having multiple mental health diagnoses. The care plan and medication records lacked evidence of specific target symptoms and monitoring processes, confirmed by the DON. This deficiency was contrary to the facility's policy on psychotropic drugs.
The facility failed to ensure medications were not expired in the 2nd floor medication room. An observation revealed expired Bisacodyl suppositories in the refrigerator, despite the manufacturer's instructions not to use them past the expiration date. An RN confirmed these medications were available for resident use, contrary to the facility's policy requiring visible expiration dates and adherence to them.
A facility failed to create a care plan for a resident with PTSD and bipolar disorder, despite recommendations for individual therapy. The resident, who was cognitively intact, did not receive behavioral health support, and the social services assistant was unaware of the need for such services. The facility's trauma-informed care policy, requiring evaluations and care plan updates, was not adhered to.
A resident with anxiety disorder and schizophrenia, who was cognitively intact, reported dissatisfaction with the activities offered by the facility, stating that they did not align with their interests. The resident's care plan noted minimal activity involvement, and the activity director could not specify the one-to-one activities provided. The facility's policy required activities to meet residents' needs and interests, but this was not effectively implemented for the resident.
A facility failed to provide necessary behavioral health services to a resident with PTSD and other mental health disorders. Despite recommendations for individual therapy, the resident did not receive the required services due to delays and lack of alternative arrangements when the initial provider was unavailable. The care plan lacked development for addressing these needs, and the social services assistant was unaware of the requirement for behavioral health services, indicating a failure in policy implementation.
A resident with moderate cognitive impairment and an indwelling catheter received improper care from a CNA, who mishandled the catheter drainage bag and used a contaminated glove to obtain wipes during perineal care. These actions violated infection prevention protocols, as confirmed by the DON.
The facility's main kitchen was inadequately staffed, resulting in late and cold meals, poor food quality, and dissatisfaction among residents. Observations and interviews revealed consistent delays in meal service, with meals often being served cold or improperly cooked. The dietary department faced significant staff turnover and was still training new staff, contributing to the ongoing issues.
The facility failed to promptly resolve grievances related to food service, with residents reporting issues such as cold meals, incorrect orders, and significant delays in service. Despite acknowledging these issues, the facility had not fully implemented a performance improvement plan, leaving grievances unresolved.
The facility failed to provide showers according to resident preferences, with several residents receiving bed baths instead. Observations noted inadequate hygiene, with some residents having noticeable body odors. Interviews revealed misunderstandings among staff regarding shower protocols, particularly for residents on COVID precautions, leading to a high number of refusals and documented bed baths.
The facility failed to provide palatable and timely meals, with residents reporting issues such as cold, tasteless food, incorrect orders, and small portions. Observations confirmed delayed meal services, and interviews revealed dissatisfaction with the food quality and service. Staffing issues in the dietary department contributed to these ongoing problems.
A staff member failed to correctly don PPE before caring for a resident on droplet/contact precautions, wearing a gown open in the front. The staff member was not concerned due to the resident's lack of symptoms. Interviews indicated a need for education on proper gown use, and the facility's policy requires gowns to protect skin and clothing during care.
Failure to Provide Adequate Behavioral Health Services for Resident with Dementia
Penalty
Summary
A facility failed to ensure that a resident with severe dementia received appropriate behavioral health care and services to attain their highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including severe early onset Alzheimer's dementia with mood disturbance, anxiety, and major depressive disorder, exhibited significant cognitive impairment and behavioral symptoms such as wandering, intrusive behaviors, and increasing aggression. Despite these symptoms, the care plan lacked comprehensive, resident-centered interventions, particularly non-pharmacological strategies, and there was no evidence of a thorough assessment addressing the resident's wandering and behavioral issues. Documentation revealed ongoing behavioral incidents, including the resident entering other residents' rooms, touching belongings, urinating in inappropriate places, and escalating physical and verbal aggression toward staff and other residents. Staff notes indicated the resident was difficult to redirect, required frequent cueing, and became more agitated as the day progressed. Multiple staff interviews confirmed that interventions were limited to redirection and medication administration, with no documentation of attempted or implemented non-drug interventions or a behavioral care plan tailored to the resident's needs. The situation culminated in a serious incident where the resident physically assaulted a staff member and attempted to harm another resident, resulting in the police being called and the resident being arrested for aggravated assault. Interviews with facility leadership and staff confirmed gaps in documentation, assessment, and care planning, as well as a lack of clear communication and follow-through regarding behavioral interventions. The facility did not provide evidence of a systematic approach to managing the resident's behavioral health needs, contributing to the actual harm experienced.
Failure to Ensure Safe and Orderly Discharge Following Resident Assault
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including diabetes, dementia, anxiety disorder, and depression, was admitted to the facility and later became involved in a serious incident. The resident entered another resident's room, became physically aggressive, and assaulted an LPN by stepping on her foot and attempting to strangle her. The police were called, and the resident was arrested for aggravated assault and removed from the facility. Documentation shows that the facility issued an immediate discharge notice to the resident, citing endangerment to the safety and health of individuals in the facility. The facility's records indicate that after the resident's arrest, the discharge notice was delivered to the local detention center and sent to the resident and their representative by mail. The facility also notified the resident's son/POA about the arrest and discharge. However, there was no evidence in the medical record that the facility ensured the receiving facility (the detention center) could meet the resident's needs or that appropriate information was communicated to the receiving provider. Additionally, there was no documentation from a healthcare provider justifying the necessity of the discharge. A review of the facility's transfer and discharge policy requires that, in cases of discharge for safety reasons, the facility must document the transfer or discharge in the medical record and communicate appropriate information to the receiving care institution or provider. The policy outlines specific information that must be provided, such as practitioner contact information, resident representative information, advanced directives, special instructions, care plan goals, and other necessary information. The facility failed to meet these requirements in this case, as confirmed by interviews with the DON and ED, who stated that no further documentation was available.
Staffing Deficiency in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews and observations. Residents reported long wait times for assistance, with some waiting up to 40 minutes for call lights to be answered. Several residents mentioned that they did not receive scheduled showers due to staffing shortages. Observations on different floors confirmed that the number of Certified Nursing Assistants (CNAs) was below the required levels, with only two CNAs available to care for a large number of residents. Interviews with staff, including CNAs and an LPN, corroborated the residents' claims, revealing that the staffing levels were inadequate to provide timely care. The facility's staffing issues were further highlighted by the review of payroll-based journal data, which showed low weekend staffing and a consistent one-star staff rating over four quarters. The facility's daily staff postings inaccurately included hours from Hospitality Aides, who are not qualified to provide direct patient care, as part of the nursing staff hours. The Director of Nursing confirmed that Hospitality Aides were counted as part of the nursing staff, despite their inability to provide direct care. The facility's self-assessment indicated a need for 160 CNA care hours, but the actual average was only 148 hours, further demonstrating the staffing deficiency.
Failure to Identify and Monitor Target Symptoms for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for a resident receiving psychotropic medications. The resident, who was cognitively intact with a BIMS score of 12 out of 15, had diagnoses including anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and post-traumatic stress disorder. The resident was prescribed risperidone for schizoaffective disorder and buspirone for anxiety disorder. However, the care plan did not specify target symptoms for each medication, and the medication administration records for June, July, and August 2024 lacked evidence of a process to monitor these symptoms. An interview with the Director of Nursing confirmed that the facility had not identified medication-specific target symptoms, which hindered their ability to evaluate the effectiveness of the medications. The facility's policy on psychotropic drugs, last revised in October 2022, emphasized the importance of validating appropriate diagnoses and recognizing the underlying causes of symptoms to treat conditions appropriately. Despite this policy, the facility did not adhere to these guidelines, resulting in a deficiency in monitoring and managing the resident's psychotropic medication regimen.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to ensure that medications available for resident use were not expired in one of the three storage areas, specifically the 2nd floor medication room. During an observation of the medication storage room refrigerator, a box of Bisacodyl suppositories was found with an expiration date that had already passed. The manufacturer's literature indicated that the medication should not be used after the expiration date, which was clearly marked on the carton and blister pack. An interview with an RN confirmed that all medications stored in the refrigerator were available for resident use. The facility's policy on floor stock medications required that expiration dates and lot numbers be clearly visible, and that medications should not be used beyond the expiration date on the original container or one year from the date of opening, whichever comes first.
Failure to Develop Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with post-traumatic stress disorder (PTSD) and bipolar disorder. The resident, who was cognitively intact with a BIMS score of 12 out of 15, had multiple diagnoses including anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. A PASRR Level II review recommended individual therapy for the resident. However, the care plan, last revised on June 30, 2024, did not include any interventions related to the resident's behavioral health needs for PTSD or bipolar disorder. Additionally, an interview with the social services assistant revealed that the resident did not receive any behavioral health support, and the assistant was unaware of the requirement for residents to receive such services. The facility's policy on trauma-informed care, last revised in October 2022, mandates that upon new admissions, a trauma-informed care evaluation is completed by a Licensed Nurse. Based on the evaluation, appropriate provider and IDT notifications should be made to support the care of residents with a history of trauma, and the care plan should be updated to include goals and interventions, including non-pharmacological means. This policy was not followed, contributing to the deficiency.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility failed to provide activities of interest for a resident who was cognitively intact and diagnosed with anxiety disorder and schizophrenia. The resident expressed dissatisfaction with the activities offered, stating that the facility did not provide activities they would like to attend, nor did it offer one-to-one activities, which the resident indicated would be appreciated. The resident's care plan, last revised in February 2024, noted little or no activity involvement due to the resident's wishes not to participate, but it also mentioned that the resident enjoys music. Interventions included encouraging participation and inviting family members to attend activities with the resident. The activity director was unable to specify what one-to-one activities were performed for the resident, despite claiming that such activities were conducted. The facility's policy on activities, last revised in July 2015, stated that activities should include individual, small and large groups, one-to-one, and independent activities to meet residents' needs, abilities, and interests. However, the policy was not effectively implemented for this resident, as evidenced by the lack of suitable activities and the resident's expressed dissatisfaction.
Failure to Provide Behavioral Health Services for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with multiple mental health disorders, including post-traumatic stress disorder (PTSD). The resident, who was cognitively intact with a BIMS score of 12 out of 15, had a PASARR Level II review recommending individual therapy. Despite this, the facility did not ensure the resident received the required mental health services. Initial attempts to schedule services with a behavioral health facility were made in April, but the process was delayed due to incomplete paperwork. By July, it was discovered that the behavioral health facility was not accepting new patients, and no alternative arrangements had been made. Additionally, the resident's care plan, last revised in June, lacked any development for addressing behavioral health needs related to PTSD or bipolar disorder. The social services assistant admitted to being unaware of the necessity for residents to receive behavioral health services, indicating a gap in the facility's understanding and implementation of required care. The facility's policies on trauma-informed care and mental health rehabilitation services were not effectively followed, as evidenced by the lack of appropriate care planning and coordination for the resident's mental health needs.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention practices during the care of a resident with moderate cognitive impairment and an indwelling catheter. The resident, who was dependent on staff for toileting hygiene, was observed being assisted by a CNA who improperly handled the catheter drainage bag. The CNA placed the drainage bag on her gown above the resident's bladder, causing urine to flow backward toward the bladder, and later placed it under the resident's wheelchair. This improper handling of the catheter drainage bag was confirmed by the Director of Nursing as inappropriate. Additionally, during perineal care, the CNA used a contaminated gloved hand to obtain more wipes from the container after cleaning feces from the resident's rectal area. This action further demonstrated a failure to adhere to infection control protocols. The facility's failure to ensure that the catheter drainage bag was positioned correctly and to maintain proper hygiene during personal care was identified as a deficiency in infection prevention practices.
Inadequate Kitchen Staffing Leads to Meal Service Deficiencies
Penalty
Summary
The facility failed to ensure adequate staffing in the main kitchen, leading to multiple grievances from residents regarding the quality and timeliness of meals. Observations and interviews revealed that meals were consistently served late, often cold, and not in accordance with the scheduled meal times. Residents reported that breakfast was always cold, meals were overcooked or not flavorful, and dinner service was delayed. Additionally, there were instances where the facility ran out of necessary food items during meal service, resulting in substitutions that were not satisfactory to the residents. Several residents expressed dissatisfaction with the quality of the food, noting that it was often dry, tough, or improperly cooked. One resident, who required a high-protein diet for wound healing, reported that the food was too tough to chew and had to resort to ordering fast food and protein shakes to meet dietary needs. Another resident mentioned that the facility's response to dining concerns was inadequate, attributing the issues to a lack of staff and difficulty in hiring new personnel. Interviews with the facility's administrator and dietary manager confirmed that the dietary department had experienced significant staff turnover and was still in the process of training new staff. The facility had recently changed food providers, which required meals to be made from scratch, further complicating the situation. The dietary department was also short-staffed due to two members being off for a traumatic event, and there were three additional staff openings. Despite having a performance improvement plan, it had not been fully implemented at the time of the survey.
Unresolved Grievances in Food Service and Palatability
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to food service and palatability, as evidenced by multiple unresolved complaints from residents. A grievance form dated 1/9/24 indicated that a resident's daughter was upset about the resident receiving a small amount of soup, and although the registered dietitian confirmed the meal was appropriately served, the resident left the facility against medical advice. Another grievance dated 3/12/24 reported cold breakfast and issues with meal timing for a resident returning from dialysis, but the grievance was not marked as resolved. Further grievances highlighted ongoing issues with meal quality and service. On 3/21/24, a resident expressed dissatisfaction with a dinner meal, stating they would prefer to eat outside food due to management's inadequacies. Another resident on the same day reported a meal as inedible, but later could not recall the grievance. On 4/2/24, multiple residents complained about overcooked chicken and slow service, and on 4/7/24, a resident received the wrong sandwich order. Observations on 4/10/24 and 4/11/24 showed significant delays in meal service, with residents waiting up to an hour for lunch, and issues with food quality and availability. Interviews with residents and staff revealed systemic issues in the dietary department, including staff turnover, a change in food providers, and inadequate staffing levels. Residents reported meals being consistently late, improperly cooked, and not following the menu. The facility's administrator and dietary manager acknowledged ongoing food service issues, attributing them to staff shortages and a recent traumatic event affecting dietary staff. Despite a performance improvement plan being developed, it had not been fully implemented, and meal-related grievances remained unresolved.
Failure to Provide Showers as Per Resident Preferences
Penalty
Summary
The facility failed to ensure that bathing was performed according to the plan of care for residents on two care units. Multiple residents reported not receiving showers as per their preferences, with some residents only receiving bed baths instead. For instance, one resident reported only receiving two showers during their stay, despite their care plan indicating a preference for twice-weekly showers. Another resident was documented as having received only six showers over several months, with numerous bed baths recorded instead. Observations and interviews revealed that some residents had noticeable body odors, indicating inadequate hygiene care. One resident expressed a preference for showers but was routinely given bed baths due to issues with water temperature. Another resident, who was in isolation, was not provided a shower despite being on the shower list, and instead, only a bed bath was offered, which the resident declined. Interviews with staff, including the social services director and the DON, confirmed that there were misunderstandings among staff regarding showering protocols, particularly for residents on COVID precautions. Staff education was conducted due to a high number of resident refusals and documented bed baths, as bed baths were not as thorough as showers in cleaning residents.
Deficiencies in Food Service Quality and Delivery
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Multiple grievances were filed by residents regarding the quality and temperature of the food served. Residents reported issues such as dry and chewy tortillas, cold breakfast meals, overcooked chicken, and meals not being flavorful. Additionally, there were complaints about incorrect meal orders, such as a resident receiving ham instead of a turkey sandwich, and burnt grilled cheese sandwiches. Observations confirmed that meal services were delayed, resulting in cold food being served to residents. Interviews with residents revealed consistent dissatisfaction with the food service, citing slow service, cold and tasteless meals, and small portions. Some residents resorted to ordering fast food or supplementing their meals with protein shakes due to the inadequacy of the facility's food service. The facility's inability to provide meals that met residents' dietary needs and preferences was evident, with reports of meals being served late and not following the menu. Residents also expressed concerns about the lack of alternatives offered and the facility's failure to address their dining concerns. The facility experienced significant staffing issues within the dietary department, with reports of staff turnover and recent changes in food providers. The new menu required meals to be made from scratch, and the facility was still in the process of training new staff. The dietary department faced challenges due to staff being off work following a traumatic event, contributing to ongoing food service issues. Despite the development of a performance improvement plan, it had not been fully implemented, and the meal issues remained unresolved at the time of the report.
Improper PPE Use for Resident on Precautions
Penalty
Summary
The facility failed to ensure that staff correctly donned personal protective equipment (PPE) before providing care to a resident on transmission-based precautions. During an observation, a staff member was seen entering the room of a resident on droplet/contact precautions with a gown worn incorrectly. The gown was tied at the neck but left open in the front, leaving the staff member unprotected. This improper donning of PPE was confirmed during an interview with the staff member, who expressed no concern about the incorrect use of the gown because the resident was not symptomatic. Further interviews revealed that the staff member required education on the proper way to wear a gown when entering the room of residents in isolation. The facility's policy on standard precautions, dated May 2015, specifies that gowns should be worn to protect skin and prevent soiling of clothing during resident care activities. The nurse manager confirmed that remedial training for donning and doffing PPE was being conducted at the facility.
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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