Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laramie Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to protect a resident with severe cognitive impairment from physical abuse by another resident. A resident with a history of agitation and physical aggression punched another resident in the face multiple times and attempted to wrap the resident's O2 tubing around the resident's neck after a confrontation near the wheelchair. Staff intervened before the tubing was placed around the neck, and the assaulted resident had redness to the cheek while the aggressive resident had broken skin on the knuckles.
The facility failed to provide enough nursing staff and did not maintain adequate CNA coverage across multiple shifts. The DON stated the schedule was built with 2 nurses per shift and a minimum CNA pattern, but survey review of PBJ data, worked schedules, and staffing declarations showed repeated shortages, including shifts with only 1 CNA overnight and other shifts with 2 to 3 CNAs. Residents and the resident council reported long call light times, delayed or missing food delivery, and difficulty getting clothing changed, and a CNA reported feeling overwhelmed by low staffing.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge notices before hospital transfers for multiple residents. The DON stated that an Interact form was sent with residents and bed-hold information was provided, but confirmed that residents or their representatives were not given the required written notice. The facility policy required a Resident Notice of Transfer or Discharge with specific information, including the reason for transfer, destination, and Ombudsman contact information.
Failure to provide bathing per the care plan for two residents. One resident who needed max assist for bathing was observed in a hospital gown with greasy, uncombed hair, and the bathing log showed missed baths and one refusal. Another resident with amputation, impaired balance, and pain was also observed with greasy, uncombed hair, and the bathing log showed limited showers despite a scheduled shower preference. CNA and DON interviews confirmed CNAs and nurses were expected to provide bathing, with no scheduled shower aides.
A facility failed to provide individualized activities of preference for several residents and did not provide weekend activities. Residents reported limited or no meaningful activity options, with one resident saying the activities were for children, another saying there was nothing to do, and a representative stating a resident liked to keep hands busy but did not participate much. Records and observations showed sparse one-to-one and group participation, no documented weekend activity participation, and no weekend activities scheduled, while staff acknowledged residents needed 7-day activity support and that weekend assistance was lacking.
Food Quality and Meal Delivery Concerns: Residents reported bland, repetitive, and sometimes unidentifiable food, small portions, extreme temperatures, and late or missing meal trays. Resident council minutes and grievance logs showed repeated complaints about food quality, tray timing, and unmet preferences, but there was no evidence of pattern tracking, meal observation, or documented dietary interventions to improve the issues.
Survey results and plans of correction for the prior 3 years were not available for review upon request. Observation of the State Survey binder showed only a 1-year public record document, an iQIES ePOC, and a complaint survey, with no notice of prior surveys, despite a framed sign stating 3 years of results. The administrator stated she was unaware the last standard survey needed to be posted in the binder.
Failure to Document and Resolve Resident Grievances: A resident reported a broken recliner, a missing large TV, and missing personal items, but staff had no grievance documentation or written resolution. Other residents and the resident council reported repeated concerns about missing clothing and late or poor-quality meals, with grievances often closed without evidence of pattern review, meal observation, or meaningful follow-up, and residents said they stopped filing grievances because they did not hear back or felt nothing changed.
Failure to promptly assess a resident after an abuse allegation. A resident with moderate cognitive impairment and multiple chronic conditions reported that another resident grabbed his/her buttock without consent. Staff placed the alleged perpetrator on 1:1, changed the room assignment, and interviewed staff, but the victim’s skin assessment was delayed for 2 days after the report.
Inaccurate MDS Assessment for Catheter and Ostomy Status: A resident’s quarterly MDS listed a BIMS score of 14/15, an indwelling catheter, and an ostomy, but observation and the medical record showed only a urinary catheter/suprapubic catheter and no ostomy. The resident had a history of neurogenic bladder and obstructive reflux uropathy, and the MDS Coordinator confirmed the ostomy entry was an MDS error caused by PCC pulling information from within the system.
Failure to Post Daily Nurse Staffing Information: The facility did not ensure the daily staff posting data was displayed in a prominent, readily accessible location for residents, staff, and visitors on one of four days. An observation showed no daily staff data sheet posted, and the DON confirmed the posting was not done that day.
A resident receiving incontinence care and treatment for an open sacral pressure ulcer was observed during wound care with staff failing to follow standard precautions. An RN moved from stool cleanup to holding the resident without doffing contaminated gloves, and a wound care nurse held the resident during incontinence care, then performed wound care using scissors kept in a pocket and not cleaned after removal before cutting a dressing. The DON confirmed tools were expected to be cleaned before use, and facility policy required semi-critical items to be disinfected or sterilized before use.
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.
The facility did not ensure the dietary manager met the required qualifications, as the manager had not completed the certified dietary manager coursework. Additionally, the facility employed two part-time dietitians who were not on-site, and the administrator confirmed the absence of a qualified dietary manager and a full-time dietitian.
The facility did not designate a qualified infection preventionist as required by their policy. The DON had been managing the infection control program without completing specialized training in infection prevention. The facility's policy requires the infection preventionist to have specialized IPC training beyond initial professional education, with evidence of training provided through a certificate or equivalent documentation.
The facility failed to maintain working ventilation systems in 7 out of 10 observed resident rooms. The maintenance director confirmed the issue during the survey. One room also had a sticky floor and a urine odor. The facility had a census of 48.
A facility failed to ensure a clean environment for a resident with incontinence, as persistent urine odors and sticky floors were observed over several days. Despite cleaning efforts, the issues remained unresolved. The housekeeping manager noted increased urination and the inability to perform a heavy mop due to fall risk, with nursing staff having access to a mop bucket for cleaning.
The facility failed to ensure proper labeling and expiration management of medications in two medication storage areas. An insulin pen was found without an open date label, and an LPN was unaware if it was within the usable timeframe. The DON confirmed that insulin pens should be labeled and not administered if not labeled. Additionally, a multidose bottle of Aspirin was found with an expired manufacturer's date, and an RN acknowledged it should not be used past expiration. The DON expects nurses to check expiration dates before administration.
The facility failed to implement enhanced barrier precautions for residents requiring them, as observed in multiple instances where CNAs did not use proper PPE or follow infection control procedures. Staff interviews revealed a lack of awareness and training on these precautions, despite the facility's policy indicating their necessity for residents with wounds or indwelling devices.
A facility failed to identify and monitor target symptoms for a resident receiving Sertraline for anxiety with depression. Despite orders to monitor behaviors every shift, no specific target symptoms were documented in the care plan, medication administration record, or informed consent. Interviews with the DON and regional nurse confirmed this oversight, which violated the facility's policy on psychotropic medication use.
A resident with significant cognitive impairment was involved in two separate incidents of physical abuse against other residents, resulting in injury. The first incident led to a fracture for one resident, while the second involved hitting another resident. Both incidents occurred due to inadequate supervision, particularly during shift changes.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident. Resident #3 had diagnoses including COPD, Parkinson's disease, and dementia, and a BIMS assessment could not be completed, indicating severe cognitive impairment. Resident #11 also had severe cognitive impairment for daily decision making and diagnoses including Alzheimer's disease, dementia with severe agitation, and anxiety. Resident #11 had a documented history of agitation and physical aggression toward others, including grabbing, hitting, kicking, and being physically aggressive, with interventions listed as redirection, one-to-one staff monitoring, reassurance, and ensuring resident safety. During the incident, resident #11 attempted to push resident #3's wheelchair. When resident #3 told him/her to stop, resident #11 hit resident #3 in the face multiple times with a closed fist and then grabbed resident #3's oxygen tubing and attempted to place it around resident #3's neck. Staff intervened before the tubing was placed around the neck. The residents were separated and assessed, with resident #3 showing redness to the cheek area and resident #11 showing red knuckles with a break in the skin. The facility investigation and staff interviews confirmed the resident-to-resident assault and the injury to resident #3.
Inadequate Nursing Staffing and CNA Coverage
Penalty
Summary
The facility failed to provide adequate nursing staff to meet resident needs and failed to maintain a licensed nurse in charge on each shift. The facility assessment dated 12/11/2025 showed an average census of short-stay and long-stay residents and listed staffing expectations of RN, LPN, and CNA/STNA hours per resident day for day and night shifts. The DON stated she staffed the schedule with 2 day shift nurses, 2 night shift nurses, and a minimum of 2 CNAs per station during the day and night shifts, then 1 CNA per station during the overnight 10 PM through 6 AM shift, and said she was unaware of the staffing hours needed from the facility assessment. Surveyors observed staffing shortages across multiple shifts and reviewed PBJ staffing data, worked schedules from 10/1/25 through 12/21/25, and Declaration of Nursing Staffing sheets. The PBJ Staffing Data Report for FY Quarter 1 2026 triggered excessively low weekend staffing. The worked schedules showed multiple periods when CNA staffing fell below the facility's stated staffing pattern, including shifts with only 1 CNA overnight and other shifts with 2 to 3 CNAs on duty. The Declaration of Nursing Staffing sheets for 5/25/26 through 5/31/26 also showed several shifts with only 1 to 3 CNAs on duty. Resident and staff interviews supported the staffing concerns. The resident council reported long call light times and delayed or missing food delivery due to low staffing. Resident #40 stated there was not enough staff and that having only 1 person covering any length of time was not enough. Resident #5 reported the facility was short on CNAs, call lights took a long time to answer, and clothing changes were delayed for 2 to 3 days. A CNA stated low staffing was an issue, staff called out frequently, and she felt overwhelmed.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge before facility-initiated hospital transfers for 4 of 5 sampled residents (#6, #23, #30, and #31). Medical record review showed resident #6 was transferred to the hospital on 3/19/26, resident #23 on 2/10/26, resident #30 on 2/27/26, and resident #31 on 5/21/26 and 5/24/26, with no evidence that a written transfer/discharge notice had been issued to the resident and/or the resident representative for any of these transfers. During interview on 6/03/26 at 12:05 PM, the DON stated the Interact form was sent with residents when they were transferred to the hospital and that residents or their representatives were provided bed-hold information. The DON further confirmed that residents or their representatives were not provided with a written transfer/discharge notice. Review of the facility policy titled Transfer and Discharge, updated May 2025, stated that when transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge, including the date notice is given, effective date, reason for the transfer/discharge, where the resident is to be moved, and contact information for the State Long-Term Care Ombudsman.
Failure to Provide Bathing Per Care Plan
Penalty
Summary
The facility failed to ensure bathing was performed according to the plan of care for 2 residents reviewed for bathing. One resident was admitted to the facility and had care plans showing a need for maximum assistance with bathing and a bathing schedule of every other day before hospitalization. On observation, the resident was in bed wearing a hospital gown and wrap-around brief, and the hair appeared greasy and uncombed. The bathing log showed the resident preferred bathing on Tuesday and Friday afternoons, but only received bed baths on 5/6, 5/18, and 5/26; the resident refused on 5/12, and bathing did not occur on 5/15 and 5/19. The second resident had multiple hospital transfers and a care plan identifying risk for ADL self-care performance deficit related to amputation, impaired balance, and pain, with maximum assistance needed for bathing and encouragement to bathe on scheduled shower days. On observation, the resident wore a hospital gown and had long hair that appeared greasy and uncombed, and this appearance continued on a later observation. The bathing log showed the resident preferred showers on Tuesday and Friday afternoons, but only received showers on 4/29, 5/8, and 5/9, with one documented refusal on 5/12. CNA and DON interviews confirmed there were no scheduled shower aides, CNAs were expected to provide bathing, and when baths were missed it was not usually due to resident refusals.
Failure to Provide Individualized and Weekend Activities
Penalty
Summary
The facility failed to ensure individual activities of preference were provided to 4 of 4 sampled residents (#4, #8, #23, and #30) reviewed for activities, and weekend activities were not provided to 5 of 5 sampled residents (#4, #8, #23, #30, and #40). The deficiency was verified during the confidential resident council meeting and through observation, resident and representative interviews, staff interviews, medical record review, and review of the activity calendar and participation logs. Resident #4’s care plan included psychosocial well-being and one-to-one interventions, but the resident stated the activities were for young children and not older adults, so the resident did not participate, though resident council was attended when informed. The Social Worker stated the resident had not participated in activities since admission, aside from occasionally coming out of the room to talk with staff. The activity logs showed independent activity participation 58 of 94 opportunities and one-to-one participation 1 of 94 opportunities, with no documented weekend participation. Resident #8’s care plan included escorting to activities and one-to-one visits twice weekly, but the logs showed one-to-one participation only 2 of 94 opportunities, group activity 2 of 94 opportunities, independent activity 51 of 94 opportunities, and no weekend participation. Resident #23’s care plan directed staff to get the resident out of the room daily to avoid self-isolation, but the resident stated there was nothing to do, was observed remaining in the room throughout the survey, and the logs showed mostly independent activity with only 1 group activity and 4 one-to-one activities, with no weekend participation. Resident #30 identified keeping hands busy as important, with one-to-one visits planned 3 times per week, yet the resident was observed in bed, in a wheelchair by the nurses’ station, and in the dining room without being seen in activities. The resident representative said the resident did not participate in many activities and liked to do things with the hands, while the activity director said the resident participated in trivia, bingo, people watching, snacks, walking with one-to-one support, and movie/coffee activities, and that one-to-one was sometimes documented as independent. The activity director also stated she provided one-to-one visits when residents did not join groups, did rounds to assess daily preferences, and that weekend activities were expected 7 days a week, but the weekly agenda showed no weekend activities scheduled and residents reported no staff assistance on weekends.
Food Quality and Meal Delivery Concerns
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs, taking resident preferences into account. During observation, lunch trays were being delivered, and multiple residents reported concerns with food quality and meal service. Resident interviews described food that was not always what was listed on the menu, was sometimes difficult to identify by sight or taste, had extreme temperatures, was bland, repetitive, and often served in small portions. One resident also reported late meal trays and having to look for a meal tray that had been left in an unmanned cart in the dining room. Resident council discussions and grievance records showed repeated complaints about food quality, tray timing, and preferences not being followed over several months. The resident council noted that these issues had been discussed at food committee meetings, and residents often chose not to file grievances because they felt complaints were not being looked into appropriately and they did not always hear back on the resolution. The grievance log documented 15 food-related grievances, including late and missing trays and food quality concerns, but resolutions were based on meal pass documentation showing trays were passed within allotted time frames, with no evidence of pattern tracking, meal time observation, or food quality review. The dietary manager confirmed awareness of the concerns but could not provide documentation of interventions or system changes to improve delays or food quality.
Survey Results Not Available for Review
Penalty
Summary
The facility failed to ensure that recertification and complaint survey reports, along with any plans of correction from the 3 preceding years, were available for any individual to review upon request. On 5/31/26 at 3:20 PM, observation of the State Survey binder showed a document labeled "State Surveys Public Record 1 year," along with an iQIES ePOC dated 2/24/26 and a complaint survey 2567 dated 2/12/26. The front of the binder contained a piece of tape marked "updated 2/26/26," and there was no notice of prior surveys. A framed notice on the wall above the binder holder stated "State Surveys & Plan of Corrections, Three years of Results." On 6/1/26 at 9:00 AM, the administrator stated she was unaware that the last standard survey needed to be posted in the binder as well.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly obtain grievances and maintain evidence of appropriate action and issuance of grievance decisions for 4 of 8 residents reviewed for grievances. Resident #4 reported multiple concerns, including a cloth recliner with stuffing exposed from the armrest, a personal large-screen TV that was reportedly hit by lightning and replaced with a smaller TV, and missing clothing and a blanket. Observation confirmed the recliner had a torn arm with exposed stuffing and only a small TV was present in the room. The infection control nurse and maintenance director both acknowledged awareness of the broken chair, and the maintenance director also acknowledged the TV issue, but neither had documentation of their attempts to resolve the concerns or filed grievances. The DON could not locate any grievance or documentation related to the recliner or missing TV, and records from prior maintenance leadership were reported lost after a change of ownership. Resident council interviews and grievance record review showed residents often chose not to file grievances because they felt complaints were not being looked into appropriately and they did not hear back on resolutions. The grievance log and council minutes showed repeated complaints about missing clothing/items and food timing and palatability, including 15 food-related grievances in March through May 2026, but the documented resolutions relied on meal pass time checks and found the grievances unfounded without evidence of pattern tracking, meal-time observation, or food quality review. Additional interviews with residents #40, #47, and #15 showed they had missing clothing or late meal tray concerns but did not submit grievances because prior complaints had not resulted in replacement items or meaningful resolution, and one resident reported being told grievances did not happen.
Failure to promptly assess a resident after an abuse allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of physical abuse involving two residents, including resident #47 and resident #30. The allegation was reported on 5/14/26, and the facility did investigate by placing a 1:1 on the alleged perpetrator right away, changing the perpetrator’s room to a different hall, interviewing others and staff, and providing abuse education to staff. However, the facility did not assess the victim for injuries right away and waited 2 days to complete the skin assessment. Resident #47 had a quarterly MDS showing a BIMS score of 12 out of 15, indicating moderate cognitive impairment, along with verbal behavioral symptoms directed toward others and diagnoses including type 2 diabetes mellitus, polyneuropathy, chronic pain, and tension-type headache. Resident #30 had a significant change MDS showing short- and long-term memory problems and diagnoses including non-traumatic brain dysfunction, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, non-Alzheimer's dementia, and age-related cognitive decline. During interview, the victim stated resident #30 motioned him/her over, then grabbed the victim’s left buttock with his/her right hand without welcome or consent. The victim reported the incident to social services, and staff interviews confirmed the report involved an inappropriate comment and that the victim was escorted to social services.
Inaccurate MDS Assessment for Catheter and Ostomy Status
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident whose quarterly MDS dated 5/4/26 listed a BIMS score of 14 out of 15, an indwelling catheter, and an ostomy. During observation on 5/31/26, the resident was seen sitting in the room with urinary foley catheter tubing and a catheter collection bag present, and the resident stated staff took care of the catheter and collection bag and that only a urinary catheter was present. The medical record showed a history of neurogenic bladder and obstructive reflux uropathy, a care plan for an indwelling urinary catheter, and physician orders for a suprapubic catheter 16 Fr with a 10 cc balloon as needed for damage, occlusion, or obtaining a UA. The record contained no mention of an ostomy. The MDS Coordinator stated PCC automatically pulled ostomy information into the system, that she did not catch it, and confirmed it was an MDS error.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents, staff, and visitors for 1 of 4 days, Sunday. On 5/31/26 at 3:18 PM, observation showed there was no daily staff data sheet posted. During an interview on 5/31/26 at 4:45 PM, the DON stated the facility failed to post the daily staff posting data sheet for that day.
Failure to Maintain Standard Precautions and Clean Wound Care Tools
Penalty
Summary
Standard precautions were not implemented during wound care for a resident with incontinence and an open sacral pressure ulcer. During observation, RN #2 entered the room to clean the resident of stool and donned gloves and a gown, then moved to the other side of the bed to hold the resident on his/her side for wound care without removing the contaminated gloves. The wound care nurse also donned gloves and a gown, held the resident on his/her side during incontinence care, and then moved to the other side of the bed to perform care on the open sacral pressure ulcer. During the same observation, the wound care nurse opened a calcium alginate dressing and had a coworker retrieve scissors from his pocket. He used the scissors to cut the dressing to wound size and then returned the scissors to his pocket. In interview, the wound care nurse stated the scissors had been kept in a plastic bag inside his pocket and confirmed he did not clean them after removing them from his pocket before using them on the wound dressing. The DON stated the expectation was that all tools would be cleaned before use. The facility policy identified semi-critical items as items that may contact mucous membranes or non-intact skin and stated critical and semi-critical items are sterilized or disinfected in a central processing location and stored appropriately until use.
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.
Deficiency in Dietary Management Qualifications
Penalty
Summary
The facility failed to ensure that the dietary manager met the required qualifications. During an interview, the dietary manager disclosed that they had not yet completed the certified dietary manager coursework, with one month remaining. Additionally, the facility employed two part-time dietitians who were not present on-site. The administrator confirmed that the facility lacked a qualified dietary manager and a full-time dietitian, contributing to the deficiency.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual as the infection preventionist, as required by their policy. The Director of Nursing (DON) had been covering the infection control program since May, but had not completed any specialized training in infection prevention. The facility's policy, last revised in September 2022, mandates that the infection preventionist must have specialized infection prevention and control (IPC) training beyond initial professional training or education before assuming the role, with evidence of training provided through a certificate or equivalent documentation.
Ventilation System Failure in Resident Rooms
Penalty
Summary
The facility failed to ensure proper ventilation in 7 out of 10 resident rooms observed during a survey. Observations conducted on 10/10/24 revealed that the ventilation systems in these rooms were not functioning. The maintenance director confirmed the non-functioning ventilation in several rooms during the survey. Additionally, one room was noted to have a sticky floor and a smell of urine, further confirmed by the maintenance director. The facility had a census of 48 at the time of the survey.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and odor-free environment for a resident with bowel and bladder incontinence. Observations over several days revealed a persistent strong urine odor and sticky floors in the resident's room, which were noticeable even in the hallway. Despite cleaning efforts by housekeeping staff, the issues remained unresolved. The resident, although unable to smell the odors, requested additional cleaning due to the sticky floors. The housekeeping manager acknowledged the problem, citing increased urination on the floor and the inability to perform a heavy mop while the resident was present due to fall risk. Nursing staff had access to a mop bucket for cleaning when housekeeping was unavailable.
Medication Labeling and Expiration Management Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and expiration management of medications in two of its medication storage areas. During an observation of the 100 hall medication cart, an Insulin Glargine pen for a resident was found without an open date label, making it unclear when the medication should be discarded. An LPN confirmed that the insulin should have been labeled with the date it was opened and a 28-day expiration date, but she was unaware if the insulin was still within the usable timeframe. The Director of Nursing (DON) confirmed that insulin pens should be labeled with the open date and should not be administered if not labeled. Additionally, an observation of the 200 hall medication cart revealed a multidose bottle of Aspirin 81 mg tablets with an expired manufacturer's date. An RN acknowledged that multidose medication bottles should not be used past their expiration date. The DON stated that her expectation is for nurses to check expiration dates before administering medications. The facility's policy on administering medications also requires checking the expiration or beyond-use date prior to administration.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control procedures for four residents requiring enhanced barrier precautions. Observations revealed that CNAs did not use enhanced barrier precautions during care activities. For instance, a CNA reconnected a wound vacuum tubing that had fallen on the floor without disinfecting it, and another CNA touched various clean surfaces with soiled gloves after performing perineal care. Additionally, catheter care was performed without the necessary enhanced barrier precautions, and there was a lack of signage and PPE in the resident's room. Further interviews with staff, including CNAs and the DON, indicated a lack of awareness and training regarding enhanced barrier precautions. The facility's policy on enhanced barrier precautions was not effectively communicated or implemented, as evidenced by staff not knowing about the precautions until the day of the survey. The policy review showed that enhanced barrier precautions are necessary for residents with wounds or indwelling medical devices, but these were not followed, leading to potential infection control breaches.
Failure to Identify and Monitor Target Symptoms for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for a resident receiving psychotropic medication, specifically Sertraline, for anxiety with depression. The quarterly MDS assessment indicated that the resident had diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression. Despite physician orders requiring behaviors related to Sertraline use to be monitored every shift, there were no specific target symptoms identified in the medication orders, care plan, medication administration record, or informed consent for the medication. Interviews with the Director of Nursing (DON) and regional nurse confirmed the absence of resident or medication-specific target symptoms. The facility's policy on psychotropic medication use requires an evaluation to determine if signs and symptoms are clinically significant enough to warrant medication therapy. However, this evaluation was not adequately documented or implemented for the resident in question, leading to the deficiency identified by the surveyors.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in harm to two residents. Resident #5, who had moderate cognitive impairment and various medical conditions, was injured in an altercation with resident #1, who also had significant cognitive impairment and other health issues. During the incident, resident #1 entered resident #5's room, became agitated, and pushed resident #5, causing them to fall and sustain a fracture. This incident was documented in an incident report and confirmed through a facility investigation. A subsequent incident involved resident #1 entering the room of resident #2, who had significant cognitive impairment and multiple diagnoses. Resident #1 hit resident #2 on the shoulder, causing slight redness. This altercation occurred during a shift change when resident #1 was unsupervised, despite being on 1:1 observation. The facility's investigation substantiated both incidents, indicating a failure to adequately supervise and protect residents from abuse.
Removal Plan
- Implemented a quality assessment process improvement (QAPI) program addressing resident-to-resident abuse.
- Placed resident #1 on increased observation.
- Provided staff training including behavior management and working with residents with behaviors to decrease the risk of aggression towards other residents.
- Placed resident #1 on 1:1 observation.
- Plans made to transfer resident #1 to another facility.
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