Mountain View Skilled Nursing Community At Wlrc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lander, Wyoming.
- Location
- 8204 Wyoming State Highway 789, Lander, Wyoming 82520
- CMS Provider Number
- 535058
- Inspections on file
- 16
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mountain View Skilled Nursing Community At Wlrc during CMS and state inspections, most recent first.
Two residents experienced physical harm after repeated altercations involving physical aggression and verbal provocations, including derogatory name-calling and accusations, with staff unable to consistently prevent or de-escalate these incidents. Injuries such as abrasions, swelling, and bruising were documented, and staff interviews confirmed ongoing difficulties in managing the behaviors of those involved.
A resident with multiple behavioral health diagnoses repeatedly engaged in verbally and physically aggressive behavior toward others, leading to several altercations and minor injuries. Staff interventions, primarily verbal redirection, were inconsistently effective, and staff expressed uncertainty about managing the resident's behaviors. The facility did not provide necessary behavioral health care and services, resulting in actual harm.
Two residents were involved in a verbal and physical altercation, but the incident was not reported to the state survey agency within the required timeframe due to lack of staff access to the reporting system on weekends, contrary to facility policy.
A resident was transferred to the hospital due to an acute change of condition, but the facility failed to provide a written transfer notice to the resident or their representative. The social services director confirmed the absence of the notice, which is required by the facility's policy for emergency transfers.
The facility failed to provide a resident with written information on the bed-hold policy during a hospital transfer for an acute condition. The social services director confirmed the absence of the bed-hold notice, despite the facility's policy requiring such information to be given upon admission and before any transfer.
The facility failed to provide a required annual comprehensive psychiatric evaluation for a resident with serious mental illness and severe cognitive impairment, as identified in the PASARR Level II assessment. The resident's last psychiatric evaluation was completed over two years ago, and the social services director confirmed the deficiency.
A facility failed to offer a pneumococcal vaccine to a resident as per CDC recommendations. The resident's MDS assessment indicated the vaccine was not up-to-date, and there was no record of prior vaccination. The DON confirmed the vaccine was not offered, despite facility policy requiring all residents to be offered vaccines unless contraindicated or previously vaccinated.
The facility did not conduct an annual review of its IPCP policies, including the Antibiotic Stewardship, Written Exposure Control Plan & Health Outbreak Guidelines, and Vaccination of Residents policies. An interview with the DON confirmed the lack of required annual reviews, affecting a census of 13 residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in actual physical harm to two residents. Multiple incidents were documented in which one resident, who had diagnoses including schizophrenia and bipolar disorder and was cognitively intact, engaged in physical altercations with another resident. These altercations were often triggered by verbal provocations, including derogatory name-calling and accusations of theft. The aggressive behaviors included throwing objects, physical fighting, and attempts to punch, kick, or otherwise harm another resident. In several instances, staff had to intervene to separate the residents, and minor injuries such as abrasions and swelling were noted. Another resident, who had cerebral palsy, seizure disorder, and anxiety disorder, and used a motorized wheelchair, was also involved in a physical altercation with a peer. This resident, described as non-verbal and generally getting along with others except for one individual, was observed hitting and being hit by another resident after an exchange of words. The altercation resulted in visible injuries, including swelling and bruising to the eye and a small scrape. Staff and witnesses reported that the instigating resident had a history of taunting and using derogatory language toward others, which contributed to the escalation of these incidents. Interviews with staff confirmed that the resident who frequently used derogatory language was known to antagonize others and that redirection efforts by staff were not always effective. Staff also reported that some residents would attempt to avoid the instigating resident by staying in their rooms, and that fear and distress were present among those targeted. Despite the facility's policy stating that all residents would be protected from abuse and neglect, the documented incidents demonstrate that the facility did not effectively prevent or intervene in resident-to-resident abuse, resulting in physical harm and emotional distress.
Failure to Provide Effective Behavioral Health Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with multiple diagnoses, including non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, depression, and psychotic disorder. The resident was cognitively intact but exhibited frequent verbal and physical behavioral symptoms directed at both staff and other residents. The care plan included interventions such as redirection, support to ignore provocations, and escalation to nursing or provider involvement if needed. However, staff interviews and incident reports revealed that these interventions were inconsistently implemented and often ineffective in managing the resident's behaviors. Multiple documented incidents occurred in which the resident engaged in verbally abusive and derogatory behavior toward other residents, leading to physical altercations. These included name-calling, threats, and provoking other residents, which resulted in several physical confrontations, some causing minor injuries such as abrasions and scratches. Staff consistently reported that their primary intervention was to tell the resident to stop, which was not reliably effective. In several cases, the resident's behavior escalated to the point where other residents retaliated physically, and staff were unable to de-escalate the situation or prevent harm. Interviews with CNAs and an RN indicated a lack of effective behavioral health interventions and uncertainty among staff regarding how to manage the resident's behaviors. Staff described the resident as persistently agitating others and noted that redirection and verbal prompts were insufficient. The repeated incidents and staff accounts demonstrate that the facility did not ensure the resident received the necessary behavioral health care and services to maintain the highest practicable physical, mental, and psychosocial well-being, resulting in actual harm.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse involving two residents. An incident occurred in which one resident verbally insulted another, who then retaliated by throwing a cup of juice. The incident was documented in a facility report on the day it occurred, but was not reported to the state survey agency until three days later. Staff interviews confirmed that the delay was due to the absence of personnel with access to the incident database during weekends. Facility policy requires that such incidents be reported to the appropriate authorities within specific timeframes, which was not followed in this case.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was transferred to the hospital due to an acute change of condition. A review of the nurse progress note dated 12/16/24 indicated that the resident was transferred, but there was no evidence of a written transfer notice being issued to the resident or their representative. An interview with the social services director on 1/24/25 confirmed the inability to locate the transfer notice. The facility's policy, dated 10/28/24, requires that when a resident is transferred on an emergency basis, verbal confirmation of the transfer should be provided immediately or as soon as practicable, followed by a written notice. However, this procedure was not followed in this instance.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written information on the bed-hold policy for a resident who was transferred to the hospital due to an acute change of condition. A review of the nurse progress note dated 12/16/24 indicated that the resident was transferred, but there was no evidence that the facility issued the required written information on the bed-hold policy to the resident or their representative at the time of hospitalization. An interview with the social services director on 1/24/25 confirmed that the bed-hold notice could not be located. The facility's Bed Hold and Return policy, reviewed on 9/24/24, mandates that residents and/or their representatives be provided with written information regarding bed-hold policies upon admission and prior to any transfer.
Failure to Provide Required Psychiatric Evaluation for Resident
Penalty
Summary
The facility failed to arrange for specialized services to meet the needs of a resident as identified in the Preadmission Screening and Resident Review (PASARR) Level II assessment. The resident, who was admitted from an inpatient psychiatric hospital, was determined to have a serious mental illness and severe cognitive impairment, with a BIMS score of 3 out of 15. Diagnoses included anxiety disorder, depression, bipolar disorder, and psychotic disorder. The PASARR Level II Determination Summary Report recommended a minimum of an annual comprehensive psychiatric evaluation to clarify the current psychiatric diagnosis and appropriate treatment plan. However, the resident's medical record showed that the last psychiatric evaluation was completed on 2/1/21, and an interview with the social services director confirmed that an annual comprehensive psychiatric evaluation had not been completed as required.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered pneumococcal immunizations in accordance with CDC recommendations. A review of the quarterly MDS assessment for a resident admitted to the facility revealed that the resident's pneumococcal vaccine was not up-to-date and had not been offered. The resident's medical record showed no evidence of prior vaccination. An interview with the Director of Nursing confirmed that the resident had not been offered the vaccine. The facility's policy stated that all residents should be offered vaccines unless medically contraindicated or previously vaccinated. The CDC recommends pneumococcal vaccination for all adults who have never received a pneumococcal conjugate vaccine and are of a certain age.
Failure to Conduct Annual Review of IPCP Policies
Penalty
Summary
The facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP), as required. The review of the facility's IPCP policies revealed several concerns: the Antibiotic Stewardship policy, approved on March 11, 2022, the Written Exposure Control Plan & Health Outbreak Guidelines policy, approved on April 5, 2022, and the Vaccination of Residents policy, also approved on April 5, 2022, all showed no evidence of subsequent review. Additionally, the Infection Prevention and Control policy, approved on May 18, 2023, also lacked evidence of a subsequent review. An interview with the Director of Nursing (DON) confirmed that the IPCP policies had not been reviewed annually, as required by regulations. The facility's census at the time was 13, indicating the number of residents potentially affected by this oversight.
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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