Green House Living For Sheridan
Inspection history, citations, penalties and survey trends for this long-term care facility in Sheridan, Wyoming.
- Location
- 2311 Shirley Cove, Sheridan, Wyoming 82801
- CMS Provider Number
- 535054
- Inspections on file
- 21
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Green House Living For Sheridan during CMS and state inspections, most recent first.
The facility did not ensure accurate and completed MDS assessments for multiple residents, as several admission, quarterly, annual, and significant change MDS assessments remained in “In Progress” status at the time of review. Medical record review and staff interview confirmed that these assessments had not been updated, and the DON acknowledged they were incomplete. This was inconsistent with the facility’s MDS 3.0 Completion policy, which requires comprehensive, accurate, standardized assessments of each resident’s functional capacity using the RAI.
A cognitively impaired, non-ambulatory, incontinent resident with a history of a Stage I pressure ulcer was left in a wheelchair for most of a day without being checked or changed, provided peri care, or transferred to bed, despite facility policies requiring a check-and-change strategy and pressure ulcer prevention measures. One CNA relied on the absence of odor instead of physically assessing the resident’s continence status or skin, did not follow the usual practice of laying the resident down in the afternoon to protect skin, and was unaware of the resident’s care plan or skin issues. Another staff member later reported that the resident had not been checked or changed all day, found the brief wet, observed a sore on the resident’s bottom that may have reopened, and reported the situation to the RN.
A resident with severe cognitive impairment, non-Alzheimer’s dementia, depression, incontinence, and total dependence for ADLs had care plans addressing mixed bladder incontinence and risk for impaired skin integrity that were not updated despite documented changes in condition. Progress notes described coccyx and sacral skin breakdown, application of barrier cream and Mepilex dressings, initiation of skin treatments in the TAR, and a Braden score of 13 with multiple risk factors, yet the care plans were not revised to reflect these developments. The DON confirmed that the care plans had not been updated, contrary to facility policy requiring interdisciplinary review and revision after assessments.
A resident with moderate cognitive impairment and mobility needs fell in the bathroom after waiting an extended period for staff assistance, as the emergency call light was not answered for over 30 minutes. The resident sustained a head injury and later died from a subdural hematoma. Staff interviews and records indicated previous delays in call light response, and the call light system did not distinguish between emergency and regular calls, contributing to the delayed response.
A resident with moderate cognitive impairment and multiple diagnoses experienced severe weight loss due to the facility's failure to provide adequate nutritional support. Despite being on a fortified diet with snacks, the resident was not offered snacks during extended periods at the dining table, and the care plan did not adequately address the need for frequent feedings. The dietitian confirmed that offering snacks was not documented in the resident's medical record, contributing to the resident's severe weight loss.
The facility did not have a qualified infection preventionist to manage the infection prevention and control program. The administrator was temporarily handling the responsibilities with help from the hospital, but no staff member had the necessary specialized training. The facility had 28 residents at the time.
The facility did not implement an antibiotic stewardship program, as shown by the absence of monitoring and review of antibiotic use. A resident was prescribed Cephalexin daily for infection management without a stop date or documented physician rationale for long-term use, and staff confirmed that no review process was in place despite facility policy assigning this responsibility to the Infection Control Committee and Infection Preventionist.
The facility failed to maintain resident dignity and privacy when CNAs discussed health information loudly in front of others. Observations showed CNAs asking residents about personal health matters and discussing resident care details audibly across the room. The administrator and DON acknowledged this was inappropriate and against facility policy, which requires confidential information to be protected and discussed privately.
The facility failed to provide adequate resident choice of activities in three of four cottages, leading to deficiencies in meeting residents' needs. Observations showed residents, including those with cognitive impairments, were not consistently engaged in scheduled activities, often left idle or alone. Staff interviews revealed insufficient staffing levels to support expected activity engagement, highlighting a gap between policy and practice.
A facility failed to provide adequate staffing in one of its cottages, affecting the care of a resident with severe dementia who required significant supervision. Observations and interviews revealed that the cottage was understaffed, with only one CNA, a patient care tech, and an RN on duty. The resident's behaviors, such as wandering and agitation, required one-to-one supervision, which was not consistently available, impacting the care of other residents as well.
The facility failed to document the education, offer, refusal, or receipt of influenza and pneumococcal immunizations for several residents. A review of medical records showed no evidence of required documentation for these vaccinations, and interviews with the administrator and DON confirmed the lack of evidence. The facility's policy requires such documentation, but it was not followed, resulting in the deficiency.
A resident with severe cognitive impairment due to dementia exhibited behaviors such as agitation and wandering, which were not adequately managed by the facility. Observations and progress notes indicated a lack of sufficient supervision and engagement in activities, with staff struggling to redirect the resident effectively. The facility was understaffed, and the activities director rarely engaged with residents, leading to unmet needs in dementia care.
A resident was prescribed Cephalexin 250 mg daily for infection management without a stop date or documented physician rationale for long-term use. The facility's Antibiotic Stewardship policy, which requires evidence-based antibiotic use, was not adhered to, as confirmed by the DON and administrator.
The facility failed to serve palatable food when a lunch meal of Creamy Chicken and [NAME] Soup was observed to have a thick, clay-like texture with no visible fluid. A resident noted the soup was too thick to eat, and another expressed dissatisfaction. The dietitian confirmed the soup was improperly prepared, lacking the necessary broth as per the recipe.
The facility did not check the CNA abuse registry before allowing four CNAs to have resident contact, despite having active Wyoming certifications. Human resources staff confirmed they were unaware of the requirement to check the state CNA abuse registry.
The facility failed to ensure a safe and functional environment in three cottages, leading to significant issues for residents, including extreme room temperatures and smoking heaters. One resident was hospitalized for rehydration and suspected pneumonia due to an overheated room. The maintenance director confirmed ongoing HVAC issues, with plans to upgrade the system but no immediate resolution.
The facility failed to provide sufficient nursing staff, leading to safety concerns for residents with severe cognitive impairments. A resident with a history of wandering was found outside the facility multiple times, and staff struggled to manage the situation due to inadequate staffing. Another resident was also found outside, highlighting the facility's staffing challenges. The resignation of nine CNAs and excessive overtime further exacerbated the issue, impacting the facility's ability to meet residents' needs.
The facility failed to appoint a licensed Nursing Home Administrator as required by Wyoming regulations. The CEO was acting as the administrator without a license since February 2023, as confirmed by interviews and documentation. The board only recently became aware of this regulatory requirement.
A resident with a pulmonary disease experienced issues with their CPAP mask, causing eye irritation. Despite being cognitively intact and reporting the problem to the former DON for three months, no action was taken. The resident was advised by the SW to contact the regional ombudsman and was given the CPAP service contact number, but the facility needed to arrange a consult with a CPAP representative, which was delayed until the current DON intervened.
The facility failed to post complete 24/7 nursing staff information, missing details such as elder census and actual hours worked by CNAs, RNs, and LPNs on multiple days across different cottages. The DON confirmed the postings were incomplete.
Incomplete and Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and accurate for three of four sampled residents reviewed for MDS discrepancies. For one resident, both the admission and quarterly MDS assessments remained in “In Progress” status as of the survey review. For a second resident, the annual MDS assessment and a significant change MDS assessment were also found in “In Progress” status. For a third resident, both the admission and quarterly MDS assessments were likewise in “In Progress” status. Medical record review and staff interview confirmed that these MDS assessments had not been updated, and the DON acknowledged that the assessments were incomplete. Facility policy on MDS 3.0 Completion, as provided by the DON, states that according to federal regulations the facility must conduct initially and periodically a comprehensive, accurate, and standardized assessment of each resident’s functional capacity using the RAI specified by the state. These findings show that required MDS assessments for multiple residents were not finalized as completed assessments in accordance with the facility’s own policy and federal requirements, resulting in inaccurate or incomplete resident assessments at the time of survey review.
Neglect of Incontinent, Non-Ambulatory Resident’s Skin and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, non-ambulatory, incontinent resident from neglect by not providing necessary incontinence care, repositioning, and monitoring throughout a day. The resident had severely impaired cognitive skills, non-Alzheimer’s dementia, depression, was dependent for ADLs, and had a history of a Stage I pressure ulcer with a pressure-relieving mattress in place. On the day in question, a CNA got the resident up around late morning and, with assistance from another CNA, transferred the resident to a wheelchair for lunch. The resident ate little and was typically given a nutritional shake. One CNA reported that another CNA did not know how to make the shake and asked a third CNA to prepare it; another CNA stated she periodically gave the shake throughout the day. The resident remained seated in the wheelchair at the end of the table after the noon meal and was not moved out of the wheelchair or laid down in the afternoon as was commonly done to protect the resident’s skin. According to staff interviews, the CNA primarily responsible for the resident that day did not check or change the resident’s brief, did not provide peri care, and did not transfer the resident to bed before the end of her shift, relying instead on the absence of odor as an indicator that care was not needed. Another staff member, who was functioning as a patient care tech and not yet allowed to provide direct care independently, reported that by the time evening staff arrived, the resident had not been checked or changed all day, and she observed a sore on the resident’s bottom that may have reopened after sitting in a wet brief. The evening CNA and this staff member then changed a wet brief and provided an oral nutritional supplement, and the condition was reported to the RN. The Social Services Director confirmed that the CNA had stated she did not check the resident because she did not smell anything, despite facility policies requiring a check-and-change strategy for severely cognitively impaired, incontinent residents and a pressure ulcer prevention program focused on minimizing moisture exposure and redistributing pressure.
Failure to Update Care Plan After Skin Breakdown and Changing Risk Status
Penalty
Summary
The facility failed to ensure a resident’s care plans were updated to reflect changes in condition and new clinical findings. The resident had severely impaired cognitive skills and diagnoses including non-Alzheimer’s dementia and depression, and was incontinent, non-ambulatory, and dependent on staff for ADLs. A quarterly MDS documented these conditions, and the facility’s incident tracking log showed an alleged incident of neglect involving this resident on 12/27/25. The resident’s care plan initiated on 12/5/23 addressed mixed bladder incontinence with goals related to maintaining dignity and remaining free from skin breakdown due to incontinence and brief use, and this care plan was last revised on 11/19/24. Another care plan initiated on 3/4/24 identified the resident as at risk for impaired skin integrity, but there were no further updates to this care plan. Subsequent clinical documentation showed clear changes in the resident’s skin condition that were not incorporated into the care plans. A progress note dated 11/15/25 described the coccyx area as showing signs of breakdown, starting to open and red, with barrier cream and a silicone border Mepilex dressing applied and skin treatment orders initiated in the TAR. A progress note dated 11/18/25 documented a Braden score of 13 with detailed risk factors, including very moist skin, chairfast activity level, very limited ability to change position, adequate nutrition, and friction and shear problems. Another progress note dated 12/3/25 recorded an opening on the sacral area and application of a new Mepilex dressing. Despite these documented changes and the facility policy requiring comprehensive care plans to be reviewed and revised by the interdisciplinary team at least after each comprehensive and quarterly MDS assessment, the DON confirmed that the resident’s care plans had not been updated.
Failure to Provide Adequate Supervision and Timely Call Light Response Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment and progressive neurological conditions. The resident required partial to moderate assistance with mobility and activities of daily living, including transfers and toileting. On the day of the incident, the resident fell in the bathroom after attempting to use the toilet without assistance, resulting in a head injury and an abrasion to the left elbow. The fall was unwitnessed, and the resident was found on the floor by a CNA after the emergency bathroom call light had been activated for an extended period. Medical record review and staff interviews revealed that the resident had previously reported delays in staff response to call lights, sometimes waiting over 20 minutes, which led the resident to attempt bathroom use independently. On the day of the fall, the emergency bathroom call light was activated and remained unanswered for 36 minutes before being cancelled. The CNA who found the resident was unfamiliar with the resident and had been told the resident was fairly independent. The RN who responded noted that the resident did not normally use the call light and that no alarms were heard at the time of the incident. Further investigation showed that the call light system in use at the time did not differentiate between emergency and regular calls, as both had the same tone, making it difficult for staff to prioritize responses. The administrator confirmed that staff were expected to answer call lights immediately, but the system's limitations and staff unfamiliarity contributed to the delayed response. As a result of the fall, the resident developed a subdural hematoma and subsequently passed away.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident with moderate cognitive impairment and multiple diagnoses, including dementia and chronic obstructive pulmonary disease. The resident was on a regular fortified low sodium diet with snacks, as per physician orders. However, the resident experienced a severe weight loss of 7.34% in one month, dropping from 88.5 lbs to 82.0 lbs. Observations revealed that the resident, who appeared very thin with hollow cheeks and temples, was not offered snacks during extended periods at the dining table, despite the care plan indicating the need for small, frequent feedings and snacks. The dietitian confirmed that offering snacks was not a documented task in the resident's medical record, although it was expected that staff offer snacks, particularly between lunch and dinner. The facility's policy on weight assessment and intervention indicated that a weight loss greater than 5% in one month is severe and requires a multidisciplinary care plan. However, the resident's care plan did not adequately address the need for snacks, and there was no documentation of snacks being offered or accepted over a month-long period, contributing to the resident's severe weight loss.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure a qualified infection preventionist was designated to oversee the infection prevention and control program. During an interview with the facility administrator, it was revealed that the position of infection preventionist was vacant. The administrator was managing the program with assistance from the hospital, but confirmed that no staff member had completed specialized training in infection prevention and control. The facility had a census of 28 residents at the time of the survey.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as required, as evidenced by the lack of monitoring and review of antibiotic use. Medical record review for one resident revealed a physician order for Cephalexin 250 mg daily for infection management, initiated without a stop date and lacking documented physician rationale for long-term use, despite the resident having no current symptoms and the antibiotic being prescribed for prophylaxis. Interviews with the DON and administrator confirmed that no rationale was provided for the extended antibiotic therapy and that the facility had not established a program to review antibiotic usage. Additionally, review of the facility's policy indicated that the Infection Control Committee and Infection Preventionist were responsible for monitoring antibiotic use, but this process was not being followed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity in one of the resident cottages. During observations, it was noted that CNAs were discussing resident health information at a volume that could be heard across the room, compromising the privacy and dignity of the residents. On one occasion, a CNA asked a resident about their bowel movements in front of others, and another CNA discussed the frequency of changing another resident. On a separate occasion, CNAs discussed a resident's health information loudly from across the room. Interviews with the administrator and DON confirmed that such discussions were inappropriate and not in line with the facility's policy on maintaining dignity and confidentiality. The facility's policy emphasized that confidential clinical information should be protected and discussed outside the hearing range of residents and the public.
Deficiency in Resident Activity Engagement
Penalty
Summary
The facility failed to provide resident choice of activities for three of four resident cottages, leading to deficiencies in meeting the residents' needs. Observations and interviews revealed that scheduled activities were not consistently offered, and residents were often left without engagement. For instance, resident #6, who was cognitively intact and had a preference for group and individual activities, was not invited to participate in a card game and spent most of the time alone in the room. The activity participation record showed limited engagement in activities, with the resident attending only a few social events. Resident #11, with severe cognitive impairment, was observed to have limited participation in activities despite a care plan that emphasized the importance of group activities and personal interests like painting. The resident was seen sitting idle for extended periods, and the activity participation record indicated minimal involvement in activities beyond basic social interactions. Similarly, resident #20, also with severe cognitive impairment, was not included in group activities like Domino's and was observed wandering the cottage with minimal staff interaction, highlighting a lack of personalized engagement. Interviews with staff, including the activities director, revealed that the facility's staffing levels were insufficient to support the expected level of activity engagement. The activities director acknowledged that staff were expected to perform activities but admitted that the current staffing levels made it challenging to meet these expectations. The facility's policy on elder preference of activities emphasized the importance of resident choice, yet the observations and interviews indicated a significant gap between policy and practice, resulting in unmet resident needs for meaningful activities.
Inadequate Staffing in Cottage Leads to Deficiency
Penalty
Summary
The facility failed to ensure adequate staffing in one of its cottages, which had a census of nine residents. The deficiency was identified through observations, interviews, and a review of facility staffing. A resident with severe cognitive impairment and a history of dementia exhibited behaviors such as wandering, agitation, and attempts to leave the facility unattended. These behaviors required significant staff intervention, including redirection and one-to-one supervision, which was not consistently available. Observations on multiple occasions showed the resident attempting to exit the facility and interacting with other residents in a manner that caused distress. Staff interviews revealed that the cottage was understaffed, with only one CNA, a patient care tech, and an RN on duty at the time of the survey. The patient care tech, who was still in training, was instructed to perform resident care tasks despite not being fully qualified, highlighting the staffing inadequacies. Interviews with other residents and their representatives confirmed the perception of insufficient staffing, which impacted the care provided to all residents in the cottage. The lack of adequate staff prevented the completion of essential duties such as showers and activities, further exacerbating the situation. The facility's failure to provide sufficient staffing to meet the needs of its residents, particularly those with high care requirements, was a significant factor in the identified deficiency.
Failure to Document Immunization Education and Administration
Penalty
Summary
The facility failed to document the education, offer, refusal, or receipt of influenza and pneumococcal immunizations for four out of six sampled residents. Specifically, the immunization records for these residents lacked evidence of education about the benefits and potential side effects of the vaccines, as well as documentation of whether the vaccines were offered, refused, or administered. This deficiency was identified through a review of the medical records of residents #12, #14, #24, and #28, which showed no documentation of the required information for influenza, pneumococcal, and in some cases, COVID-19 vaccinations. An interview with the facility's administrator and director of nursing confirmed that the facility did not have evidence that the immunizations were offered or provided to the affected residents. The facility's policy, last updated in March 2022, mandates that residents or their legal representatives be educated about the vaccinations and that this education, along with any refusal or administration of the vaccines, be documented in the medical records. However, this policy was not followed for the residents in question, leading to the identified deficiency.
Inadequate Dementia Care and Supervision
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with severe cognitive impairment due to dementia, as evidenced by multiple observations and progress notes. The resident, who had a BIMS score of 0 indicating severe cognitive impairment, was noted to have behaviors such as verbal aggression, agitation, wandering, and attempts to leave the facility unattended. Despite these behaviors being documented in the care plan, the facility did not ensure adequate supervision or engagement in activities that could help manage these behaviors. Observations showed the resident ambulating independently and attempting to exit the facility, with staff struggling to redirect him/her effectively. Progress notes revealed a pattern of restlessness, agitation, and difficulty in redirecting the resident, with PRN Haldol being administered without noted effectiveness. The resident exhibited behaviors such as pacing, moving objects, and attempting to leave the facility, which were not adequately managed by the staff. Interviews with staff indicated that the cottage was understaffed, lacking a 1:1 staff member to provide necessary redirection and supervision for the resident. Additionally, the activities director rarely engaged with the residents, leading to a lack of structured activities that could have potentially calmed the resident and reduced wandering. The resident's representative expressed concerns about the lack of engagement in activities and the staff's approach to dementia care, indicating that staff were not adequately trained to handle the resident's needs. The facility's failure to provide sufficient staffing and activities, along with inadequate staff training, contributed to the resident's unmet needs and the deficiency in providing appropriate dementia care.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. A review of the physician orders revealed that a resident had been prescribed Cephalexin 250 mg daily for infection management without a specified stop date. This prescription was initially ordered on 9/27/24, following a hospital discharge note from 9/26/24, which indicated the resident had a recurrent infection but no current symptoms. The antibiotic was intended for prophylaxis, yet there was no documented physician rationale for its long-term use. An interview with the Director of Nursing (DON) and the administrator confirmed that the physician had not provided a rationale for the prolonged antibiotic use. Additionally, the facility's policy on Antibiotic Stewardship, last revised on 8/20/23, mandates that the Antibiotic Stewardship Committee supports and promotes antibiotic use protocols based on evidence appropriate for long-term care residents. However, this protocol was not followed in the case of the resident in question.
Failure to Serve Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and met the expected consistency. During an observation, the lunch meal of Creamy Chicken and [NAME] Soup was noted to have a thick texture, resembling clay, with no visible fluid. A resident commented that while the flavor was acceptable, the soup was too thick to eat, and another resident expressed dissatisfaction with the meal. The dietitian confirmed that the soup was thicker than intended due to incorrect preparation by a staff member the previous night. The recipe review indicated that the soup should have contained visible liquid broth, which was missing in the served meal.
Failure to Check CNA Abuse Registry Before Resident Contact
Penalty
Summary
The facility failed to ensure that the Certified Nursing Assistant (CNA) abuse registry was checked prior to resident contact for four CNAs. Employee file reviews for CNAs #6, #7, #8, and #9 revealed that although each had an active Wyoming certification, there was no evidence that the abuse registry was checked before they had contact with residents. An interview with two human resources staff members confirmed that the facility only checked for abuse through the department of family services and was unaware of the requirement to check the state CNA abuse registry prior to resident contact.
Facility Fails to Ensure Safe and Functional Environment in Cottages
Penalty
Summary
The facility failed to ensure a safe and functional environment in three of its cottages, leading to significant issues for residents. In one incident, a staff member found a resident's room extremely hot with a thermostat reading of 97 degrees Fahrenheit, despite being set to 71 degrees. The resident was lethargic, flushed, and had a temperature of 100.4 degrees Fahrenheit, necessitating hospital transfer for intravenous rehydration and further evaluation. The resident was later diagnosed with suspected pneumonia and ordered antibiotic therapy. Another resident reported having to be moved due to a smoking heater in their room, and issues with inconsistent room temperatures were noted by both residents and staff. The maintenance director confirmed ongoing problems with the heating and air conditioning systems in the cottages, with administration aware and working on the issues. The maintenance director revealed that the baseboard heat in the cottages had been shut off, and central heating and air conditioning were being used to regulate temperatures. An electrician tested the bathroom fan in one room but could not identify the root cause of the temperature increase. The facility had previously replaced a relay in a baseboard heater due to smoke and smell issues, and the long-term plan was to remove all 48 baseboard heaters and upgrade the HVAC system. Despite these efforts, the facility could not ensure that similar events would not occur again, as evidenced by the inability to find a malfunction in the heating lamp and the decision to turn the breaker back on while the resident remained in the room.
Staffing Deficiencies Lead to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide necessary care and safety for residents, particularly in [NAME] Cottage. Elder #1, diagnosed with severe cognitive impairment, exhibited wandering and elopement behaviors. Multiple incidents were reported where the elder attempted to leave the facility unattended, and staff struggled to manage these behaviors due to inadequate staffing. On several occasions, the elder was found outside the cottage, and staff were unable to redirect or manage the situation effectively. The staffing levels were insufficient, with only one CNA and half a nurse scheduled during night shifts, which contributed to the inability to monitor and care for the elder adequately. In another instance, Elder #5, also with severe cognitive impairment, was found outside the facility on two separate occasions. The staffing records showed inconsistencies and gaps, with many days left undocumented, indicating potential understaffing. Observations revealed that staff were often unavailable to assist residents promptly, leading to delays in care and supervision. Interviews with staff highlighted the challenges faced due to insufficient staffing, with CNAs expressing concerns about the workload and the impact on their ability to provide adequate care. The general facility faced significant staffing challenges, exacerbated by the resignation of nine CNAs in February, which was linked to management issues. The facility's payroll records showed CNAs working excessive hours, indicating a reliance on overtime to cover staffing shortages. The human resources director confirmed the facility had several CNA openings and acknowledged scheduling errors. These staffing deficiencies directly impacted the facility's ability to meet the needs of its residents, compromising their safety and well-being.
Failure to Appoint Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to appoint a licensed Nursing Home Administrator (NHA) as required by the Wyoming Board of Nursing Home Administrators. The Wyoming Nursing Home Administrators Chapter 2 Rules, effective since December 19, 2019, mandate that no individual can perform functions specific to a Nursing Home Administrator without being licensed by the Board. Despite this requirement, the facility's CEO was named as the new Administrator/Director on a Healthcare Facility Change in Personnel form dated February 13, 2023, without a Wyoming professional license number. The facility assessment updated on January 29, 2024, listed a CEO on staff but did not indicate the employment of a licensed NHA. Interviews conducted during the survey revealed further deficiencies. The CEO confirmed that she held the title of CEO and did not possess a license from the Wyoming Board of Nursing Home Administrators. Additionally, the facility was unable to provide a job description for either the CEO or an NHA. The president of the Board of Directors acknowledged that the board had only recently become aware of the regulatory requirement and that the CEO had been acting as the nursing home administrator since February 2023. These findings indicate a clear violation of the licensure requirements for nursing home administrators in Wyoming.
Failure to Address CPAP Mask Issues for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a diagnosis of an unspecified pulmonary disease, such as asthma, chronic obstructive pulmonary disease, or chronic lung disease. The resident, who was cognitively intact with a BIMS score of 15 out of 15, reported issues with their CPAP mask not fitting properly, causing eye irritation. Despite raising these concerns with the former Director of Nursing (DON) over a period of approximately three months, no action was taken. The resident attempted to contact the respiratory service company directly but was informed that the inquiry had to be made by the DON. A communication note from 2/26/24 indicated that the resident was advised by the Social Worker (SW) to contact the regional ombudsman and was provided with the CPAP service contact number. However, the facility was responsible for setting up a consult with a CPAP representative, which had not been done until the current DON called the representative on 3/19/24.
Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted 24/7 nursing staff information included all required details. A review of the daily nurse staffing information for Founders Cottage, [NAME] Cottage, and another [NAME] Cottage revealed that on multiple days, the postings did not include the elder census, the total number, and actual hours worked by Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) per shift. Specifically, Founders Cottage had 14 out of 47 days with missing information, [NAME] Cottage had 14 out of 46 days, and the other [NAME] Cottage had 29 out of 47 days with incomplete postings. An interview with the Director of Nursing (DON) confirmed the incompleteness of the daily nurse staffing data.
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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