Polaris Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheyenne, Wyoming.
- Location
- 2700 E 12th Street, Cheyenne, Wyoming 82001
- CMS Provider Number
- 535025
- Inspections on file
- 36
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Polaris Rehabilitation And Care Center during CMS and state inspections, most recent first.
Two residents, both cognitively intact but with mobility limitations, were involved in a physical altercation in their shared room, resulting in injuries including a swollen jaw, hematoma, head abrasion, and a fractured hand. The incident was preceded by reports of fear and prior aggression, and staff responded to a commotion, finding one resident on the floor and both holding a walker. Both residents required hospital evaluation, and one was later transferred due to a blood infection and subsequently passed away.
A resident with severe cognitive impairment experienced a significant decline in functional status after the facility failed to discontinue valproic acid as ordered by a neurologist, resulting in continued administration of multiple sedating medications. Despite clear hospital discharge instructions and family requests, the facility continued unnecessary medications, leading to the resident’s decline from independent mobility to total dependence.
The facility did not provide enough nursing staff to meet the daily needs of all residents, resulting in delayed assistance with meals, bathing, toileting, and other ADLs. Residents with high care needs experienced long waits for help, missed showers, and inadequate supervision during meals. Staff interviews confirmed that staffing levels were insufficient, leading to incomplete care, increased stress, and reliance on non-nursing staff to fill gaps.
Surveyors identified deficiencies when two residents were not treated with dignity and respect. One resident, who was severely cognitively impaired and dependent on staff, experienced long delays before being served meals and was left unattended in the dining room, with only one CNA assigned to assist multiple residents. Another resident, who had hoarding behaviors, became upset after staff entered their room without consent while they were hospitalized and removed items belonging to the facility. Staff interviews confirmed inadequate staffing during meals and that the room entry was directed by the NHA.
A resident with multiple medical conditions and moderate cognitive impairment was placed on a mechanical soft chopped diet following a speech language pathology evaluation, but the resident's representative was not notified of this change as required by facility policy. Both the resident and family expressed confusion about the diet, and the NHA confirmed the lack of notification.
Two residents who required assistance with activities of daily living did not receive routine bathing as care planned. One resident, severely cognitively impaired and fully dependent, received only two baths in over three weeks, while another, who was care planned for twice-weekly showers and sometimes resisted care, received only one bed bath with no documented refusals. Documentation and interviews confirmed the lack of routine bathing and insufficient recordkeeping.
The facility did not consistently implement or monitor pressure ulcer prevention interventions for two residents at risk, resulting in the development of new pressure ulcers. In both cases, care plans called for regular skin checks and use of pressure-reducing devices, but lapses in staff practices, incomplete assessments, and inconsistent use of preventive equipment led to the identification of new wounds, including a stage 3 pressure ulcer.
Two residents did not receive timely incontinence care, including one who was left in a wet brief for approximately six hours and another who waited about an hour for assistance with a bedpan and did not receive pericare. Both incidents involved delays in staff response and unmet care needs.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on each shift, as required.
The facility did not include the total hours worked by RNs, LPNs, and CNAs on daily nurse staffing postings, as required. Staff postings only listed individual names, positions, and hours worked, but omitted the total hours for each staff category. This was confirmed by the administrator during staff interviews.
Multiple residents with significant physical and cognitive impairments did not receive routine bathing or personal hygiene assistance for extended periods, as confirmed by interviews, medical records, and grievance forms. Residents reported missed showers and delayed care, often attributed by staff to ongoing staffing shortages, with some residents going weeks without bathing and having to escalate their requests to facility leadership.
A resident with complex medical needs received a new fentanyl patch without removal of the previous one, leading to simultaneous exposure to two patches. This medication error resulted in a change in the resident's level of consciousness and required hospitalization in the ICU for an accidental opiate overdose, where the resident was treated with IV Narcan.
A resident with severe cognitive impairment was physically assaulted by another resident experiencing acute delusions and agitation, resulting in mild injury before staff intervened. The facility failed to prevent the abusive event, which violated the resident's right to be free from physical abuse.
The facility failed to document SARS-CoV-2 test results for residents and staff during a COVID-19 outbreak. Despite ongoing testing and screening, results were not consistently recorded, and the former infection preventionist had resigned. The facility's guidelines required testing until no new cases for 14 days, but documentation was incomplete.
The facility failed to communicate changes in healthcare appointments to residents or their representatives, affecting two residents. One resident's urology appointment was rescheduled without notifying the representative, and another resident's follow-up appointment was canceled without rescheduling or documentation. The DON was unaware of the communication process for appointment changes.
A resident with a tracheostomy did not receive adequate care as required, with multiple omissions in the treatment administration record. The resident reported delays in dressing changes and cannula cleaning. Staff interviews indicated occasional care refusals by the resident, but these were not documented as per facility policy. The Director of Nursing confirmed the lack of documentation or care provision, and the administrator acknowledged the absence of documented competency for the involved nurses.
The facility failed to document communication with the dialysis center for three residents receiving dialysis services. A resident scheduled for dialysis on specific days had missing documentation for several treatments. Another resident also had missing records for multiple treatments, and a third resident lacked documentation for one treatment. An RN indicated that the facility had stopped using dialysis binders to track these communications.
A facility failed to develop a complete baseline care plan for a newly admitted resident with stage 5 chronic kidney disease and dependence on dialysis. The care plan, created shortly after admission, omitted the focus area of dialysis, a critical aspect of the resident's care. This omission was confirmed by the DON.
A facility failed to update a care plan for a resident with severe cognitive impairment who smoked regularly. Despite a safe smoking assessment requiring a smoking apron, the care plan lacked goals and interventions for tobacco use. The DON confirmed the oversight, which violated the facility's policy requiring documentation of safe smoking measures in care plans.
A facility failed to conduct a safe smoking assessment for a resident who began smoking after admission, despite being initially assessed as a non-smoker. The resident was observed smoking under staff supervision, but no updated assessment was completed, contrary to facility policy. The DON confirmed the oversight, highlighting a deficiency in ensuring a safe environment.
A resident did not receive the pneumococcal immunization as per CDC guidelines. The resident had previously received the Prevnar 23 vaccine and consented to the PCV20 vaccine, but it was not administered due to an oversight. The facility's policy aligns with CDC recommendations, which state that individuals 65 or older who have only received the PPSV23 vaccine should receive either the PCV15 or PCV20 at least one year later.
The facility did not update the daily staff posting for three days, as observed on a Sunday. The posting was eventually updated later that day. The scheduler, responsible for the updates, did not work weekends and was unaware of who should update the posting during that time. The DON stated it was the manager on duty's responsibility to update the posting on weekends.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents' right to be free from physical abuse by another resident, resulting in actual harm to two residents. One resident, who was cognitively intact and dependent on staff for transfers, was involved in a physical altercation with a roommate, also cognitively intact but requiring supervision for mobility. The incident occurred in their shared room, where staff responded to a commotion and found one resident on the floor and both holding a walker. Both residents sustained injuries: one had a swollen jaw and a hematoma, while the other had a bleeding head and a fractured hand. Both were sent to the hospital for evaluation and treatment. Prior to the incident, there were indications that one resident was afraid of the other, and it was reported that the aggressive resident had previously attacked another person. The altercation was triggered when a visitor entered the room, and a misunderstanding led to one resident becoming angry and striking the other with a walker. Staff interviews confirmed that the injured resident was found on the ground, screaming for help, while the aggressor was standing over them. Law enforcement was notified, but no immediate threat was determined since the injured resident was transferred out of the facility. Medical records and interviews revealed that the injured resident was later transferred to another facility due to a blood infection affecting the spine and subsequently passed away in the hospital. The aggressive resident admitted to punching the roommate and was later involved in another episode of aggression toward staff. The facility's policy required the prevention of abuse, neglect, and exploitation, but the events leading up to and during the altercation demonstrated a failure to protect residents from physical abuse.
Failure to Discontinue Unnecessary Medications Resulting in Resident Decline
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications, resulting in a significant decline in the resident’s functional status. The resident, who was severely cognitively impaired and initially independent with mobility, was administered multiple medications including valproic acid, lacosamide, olanzapine, melatonin, and paroxetine. Despite a neurologist’s order to discontinue valproic acid and switch to lacosamide, the facility continued to administer valproic acid for an extended period. The medication administration records showed overlapping use of anticonvulsants and other psychotropic medications, with changes and discontinuations not aligning with hospital discharge instructions or family requests. The resident’s representative reported that the resident’s decline began shortly after participating in a facility event, and that the facility did not follow the neurologist’s orders to discontinue valproic acid. Hospital records indicated the resident was seen for altered mental status and somnolence, with explicit instructions to stop valproic acid and increase lacosamide if needed. However, the facility’s records showed continued administration of valproic acid even after these instructions, and the medication was not discontinued until several weeks later. Nursing notes and interviews with staff confirmed the resident’s decline in mobility and self-care, with staff unable to identify the cause at the time. Further review revealed that the resident was also receiving other medications with sedative effects, and a drug interaction check indicated a significant risk of increased sedation and drowsiness from the combination of valproic acid, olanzapine, and melatonin. Interviews with the DON and NHA confirmed a lack of awareness of the medication management issues during the period in question. The failure to appropriately manage and monitor the resident’s medication regimen led to a decline from independence to total dependence in mobility and self-care.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents on both the North and South halls, as evidenced by multiple observations, interviews, and record reviews. Residents with high acuity and total dependence on staff for activities of daily living (ADLs), such as bathing, mobility, and eating, experienced significant delays and inadequate care. For example, one resident with severe cognitive impairment and total dependence was repeatedly left waiting for meals, sometimes for extended periods, and was not consistently assisted with eating or provided with timely beverages. Bathing records showed this resident received only two baths in 22 days, despite care plans indicating a need for more frequent showers. Staff interviews confirmed that only one CNA was assigned to the dining room during meals, when ideally three were needed, resulting in delayed assistance for residents requiring help with eating. Another resident, who required extensive assistance with a bedpan and preferred morning showers, reported not receiving timely care and had to call the facility for help when call lights were not answered. Documentation and interviews revealed that this resident's requests for assistance were not promptly addressed, with call lights left on for up to an hour and staff stating they did not have time to provide care due to other duties. Resident council minutes and concern forms further corroborated ongoing issues with long call light response times, late meals, and missed showers, with residents attributing these problems to short staffing. Grievances submitted by the resident council regarding staffing concerns were not documented as being acted upon. Staff interviews consistently described an environment of inadequate staffing, high resident acuity, and insufficient supplies, leading to delays in care, incomplete ADLs, and increased staff stress. Staff reported difficulty finding assistance for two-person transfers, inability to complete showers as scheduled, and having to perform tasks outside their roles due to lack of available CNAs. Some staff admitted to transferring residents alone when two were required, and therapy staff noted that basic care was often not completed before rehabilitation sessions. Management interviews acknowledged the use of a census tool to determine staffing needs and challenges in hiring CNAs, but staff and residents continued to report unmet care needs and insufficient staffing.
Failure to Ensure Resident Dignity and Respect During Meal Service and Room Entry
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during multiple observed incidents involving two residents. One resident, who was severely cognitively impaired, totally dependent on staff for self-care and mobility, and exhibited continuous inattention and disorganized thinking, experienced significant delays in meal service and was left unattended for extended periods. Observations showed the resident was brought to the dining room and left without food for up to 37 minutes before being served, and on another occasion, was seated facing a wall with minimal engagement or supervision. Staff interviews confirmed that only one person was assigned to the dining room during meal service, despite the need for more staff to assist residents who required help with eating, resulting in residents having to wait for assistance. Another resident, who was assessed as independent in decision-making but had a care plan for hoarding behaviors, was upset after facility staff entered their room and removed personal items while the resident was hospitalized. The NHA had directed the social worker to inform several residents, including this one, that their rooms needed to be cleaned due to fire hazard concerns. The EVS manager, following the NHA's instructions, entered the resident's room without consent and removed items belonging to the facility, such as linens and clothing protectors. The resident expressed distress over the lack of consent and the handling of their personal belongings. These incidents were corroborated by staff interviews and documentation, which revealed that the facility's actions did not align with the residents' rights to dignity, respect, and involvement in decisions about their care and personal property. The lack of adequate staffing during meal times and the unauthorized entry into a resident's room while absent were key factors leading to the deficiencies identified by surveyors.
Failure to Notify Resident Representative of Diet Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in the resident's diet, as required by policy. The resident, who had a history of diabetes mellitus type 2, transient cerebral ischemic attack, Parkinson's disease, muscle weakness, and dysphagia, was assessed as moderately cognitively impaired and required assistance with daily activities. The care plan indicated the resident was at risk for nutrition-related problems and that the family had declined a recommended NPO diet, opting instead for regular chopped textures after being educated on the risks. Despite this, the resident's meal card specified a mechanical soft chopped diet for all meals, and the resident's representative was not informed of this change. Interviews with the resident and their family revealed confusion and lack of awareness regarding the diet being served. The family specifically stated they were not notified of the change from a regular to a mechanical soft diet. The NHA confirmed that the diet change was recommended following a speech language pathology evaluation and acknowledged that the family had not been notified. Review of facility policy showed that notification of a resident's representative is required when there is a significant change in the resident's status, which did not occur in this instance.
Failure to Provide Routine Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide routine bathing for two residents who required assistance with activities of daily living. One resident, who was severely cognitively impaired, totally dependent on staff for self-care, and exhibited continuous inattention and disorganized thinking, was care planned to receive showers twice weekly. However, documentation showed that over a 22-day period, this resident received only two baths, and the accuracy of this documentation was confirmed by an LPN. The resident's representative also reported that the facility did not follow through with promised bathing. Another resident, assessed as independent in decision-making and not coded as rejecting care, was care planned to receive showers twice weekly in the morning. The care plan also noted occasional resistance to bathing, with interventions to reassure and reattempt care, and to document refusals. However, records indicated that the resident received only one bed bath during the review period, with no documentation of refusals, despite staff education efforts. There was a lack of further documentation to support that bathing was offered or refused as required.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent the development of pressure ulcers for two residents identified as being at risk. One resident, who was severely cognitively impaired and had multiple comorbidities including dementia, diabetes, malnutrition, and mobility limitations, was documented as requiring assistance with most activities of daily living and was noted to be at risk for pressure ulcers. Despite care plans indicating the use of pressure-reducing devices and weekly skin checks, the resident developed multiple new wounds, including a stage 3 pressure ulcer. Observations and interviews revealed that interventions such as offloading devices were not consistently in use, and staff did not always remove socks during skin assessments, potentially missing early signs of skin breakdown. Another resident, also at risk for pressure ulcers and requiring moderate assistance with daily activities, was found to have developed a sacral pressure ulcer that was acquired in-house. Nursing notes indicated the presence of an unassessed wound with odor and abnormal appearance, and subsequent documentation confirmed the wound as a pressure ulcer. The care plan for this resident included weekly skin checks, but the wound was not identified in a timely manner, and the skin assessment did not reflect the presence of new wounds. Policy review showed that the facility's guidelines required evidence-based interventions and thorough skin inspections for residents at risk of pressure injuries. However, staff interviews and documentation revealed lapses in the implementation of these preventive measures, including incomplete skin assessments and inconsistent use of pressure-relieving devices. These failures contributed to the development of avoidable pressure ulcers in both residents.
Failure to Provide Timely Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide timely incontinence care to two residents. One resident, who was severely cognitively impaired, totally dependent on staff for all self-care and mobility, and exhibited continuous inattention and disorganized thinking, was observed sitting in various locations for approximately six hours without receiving incontinence care. During this period, the resident was moved between the dining room, hallway, therapy room, and back to the dining room before being transferred to their room for wound care. Incontinence care was not provided until after the wound care was completed, at which point staff confirmed the resident's brief was wet. Another resident, who had an indwelling catheter and was frequently incontinent of bowel, reported not receiving timely assistance with toileting. The resident had to call the facility to request help after their call light was not answered for about an hour. Documentation and interviews confirmed that the resident's request for a bedpan was delayed, and pericare was not performed. The same staff member was involved in both reported incidents, and the concern had been previously voiced by the resident.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Document Total Nursing Staff Hours on Daily Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staffing postings included the total number and actual hours worked by RNs, LPNs, and CNAs for each shift. During the review of daily staff postings over a one-month period, it was found that while staff names, positions, and individual hours worked were documented, the postings did not display the total hours worked for each category of nursing staff. This deficiency was confirmed during an interview with the administrator, who acknowledged that the required total hours for each staff category were not included in the daily postings. The facility census at the time was 69 residents. No specific resident medical history or condition was mentioned in relation to this deficiency.
Failure to Provide Routine Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide routine bathing and assistance with activities of daily living for multiple residents who were unable to perform these tasks independently. Several residents, including those with cognitive impairments, physical disabilities, and complex medical conditions such as morbid obesity, quadriplegia, and recent trauma, experienced extended periods without bathing. Documentation and interviews revealed gaps in bathing records, with some residents going up to 23 days without a bath or shower. Residents reported dissatisfaction and discomfort due to missed bathing, and some had to escalate their requests to facility leadership to receive basic hygiene care. Staffing shortages were repeatedly cited as a reason for the lack of timely care. Resident interviews and concern forms indicated that call lights were not answered promptly, and staff communicated to residents that showers and other care could not be provided due to insufficient staffing. On at least one occasion, there were no CNAs present in the building, and no baths were given that day. Resident Council and individual grievances highlighted ongoing issues with delayed or missed care, including showers, bed changes, and assistance with personal hygiene. Facility policy required that residents be provided showers according to their requests or the facility's schedule, based on safety considerations. However, the regional clinical director confirmed that bathing was not being performed as required, and there were no additional records to support that residents received the necessary care. The failure to provide routine bathing and personal hygiene assistance was substantiated through resident and staff interviews, medical record reviews, and grievance documentation.
Significant Medication Error Resulting in Opiate Overdose
Penalty
Summary
A resident with multiple diagnoses, including renal insufficiency, diabetes mellitus, and chronic pain syndrome, was prescribed a fentanyl transdermal patch to be applied every three days and morphine sulfate ER twice daily for pain management. On review of the medication administration record, it was found that the resident received both medications as ordered. However, on one occasion, a registered nurse applied a new fentanyl patch without removing the old one, as she did not see the previous patch and failed to document its removal. This resulted in the resident having two fentanyl patches applied simultaneously. Following this medication error, the resident experienced a change in level of consciousness and required hospitalization. Hospital discharge documentation confirmed the resident was admitted to the intensive care unit due to an accidental opiate overdose and was treated with intravenous Narcan. The facility's policy on controlled substances requires compliance with all laws and regulations regarding handling, storage, disposal, and documentation of controlled medications, but this was not followed in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in an incident where another resident, who also had moderate cognitive impairment and psychiatric conditions, physically assaulted them. The aggressor was found gripping the other resident's arm and making verbal threats to kill, based on delusional beliefs that the roommate had committed murders. Staff intervened by physically separating the residents and removing the aggressor from the room. The assaulted resident sustained mild redness to the arm as a result of the incident. Prior to the incident, there were no indications in the report that the facility had identified or addressed the risk of aggressive behavior from the resident who became physically and verbally abusive. The aggressor exhibited acute changes in mental status, including delusions, agitation, and confrontational behavior, which were observed by staff and documented in progress notes. The incident was witnessed by staff who intervened after hearing raised voices and observing the physical altercation in progress. The facility's policies on resident rights and abuse prevention require protection from physical and psychosocial harm. However, the report documents that the resident's right to be free from physical abuse was not upheld, as the physical assault occurred before staff intervention. The deficiency centers on the facility's failure to prevent the abusive event, resulting in harm to a resident.
Inadequate Documentation of COVID-19 Testing During Outbreak
Penalty
Summary
The facility failed to ensure a system was in place for documenting resident and staff SARS-CoV-2 test results during a COVID-19 outbreak. The outbreak records showed that staff members tested positive on two consecutive days, and residents were tested on multiple dates, with several testing positive. Despite ongoing testing and screening of staff and residents, there was a lack of documentation for tests conducted after a certain date. Interviews with staff revealed that testing was performed as instructed, but results were not consistently documented. The former infection preventionist had resigned, and the facility's COVID-19 guidelines required testing twice a week until no new cases were reported for 14 days. However, the facility's documentation was incomplete, with no records of testing results after a specific date, despite verbal confirmations of continued testing. The NHA confirmed the outbreak was resolved, but the lack of documentation did not align with the facility's guidelines for outbreak resolution.
Failure to Communicate Changes in Resident Appointments
Penalty
Summary
The facility failed to ensure that changes in healthcare appointments were communicated to residents or their representatives, affecting two residents reviewed for post-hospitalization follow-up appointments. For one resident, an appointment with a urologist was initially scheduled and confirmed for a specific date, but was rescheduled by the facility without notifying the resident's representative. This led to a family member arriving for the original appointment only to find it had been moved. The director of social services had no documentation of the change, and the receptionist deleted the original appointment from the calendar without rescheduling it, leaving no record of the change in the resident's medical record. For another resident, a follow-up appointment was scheduled but later canceled by the provider's office, with no rescheduling or documentation of the cancellation in the resident's medical record. The receptionist confirmed the cancellation but did not update the appointment calendar. The director of social services indicated that appointment changes were managed by the DON and the receptionist, but the DON was unaware of how these changes were communicated, indicating a lack of a systematic process for managing and communicating appointment changes.
Deficiency in Tracheostomy Care Documentation and Performance
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident with a tracheostomy, as evidenced by multiple omissions in the treatment administration record (TAR). The resident, who had a history of acute respiratory failure and other comorbidities, reported that the tracheostomy dressing had not been changed for three days, and the cannula had not been cleaned or changed for five days. The TAR showed several instances where required tracheostomy care, such as cleaning or changing the inner cannula, changing trach ties, observing skin integrity, and suctioning the tracheostomy tube, was not performed or documented. Additionally, there was no evidence of education or competency for the staff members who provided care to the resident. Interviews with staff revealed that the resident sometimes refused care, and there was a lack of documentation regarding these refusals. The Director of Nursing confirmed that the omissions in the TAR were due to either the care not being provided or not being documented. Furthermore, the facility's policy on notification of changes required documentation of care refusals, which was not adhered to. The administrator considered the involved nurses as subject matter experts but acknowledged the absence of documented competency for them.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to ensure proper documentation of communication with the dialysis center for three residents receiving dialysis services. Resident #11, who was admitted and readmitted to the facility, was scheduled for dialysis treatments every Monday, Wednesday, and Friday. However, the Dialysis Communication Record forms for May and June 2024 showed missing documentation for several treatment dates, including 5/17, 5/31, 6/12, 6/17, 6/19, 6/21, and 6/24. Similarly, resident #35, who was admitted to the facility and received dialysis every Tuesday, Thursday, and Saturday, had missing documentation for treatments on 3/5, 3/7, 3/9, 3/21, 6/4, 6/6, and 6/8. Additionally, resident #117, who was also scheduled for dialysis every Monday, Wednesday, and Friday, lacked documentation for the 6/12 treatment. An interview with RN #1 revealed that the facility had previously used dialysis binders to track communication forms but had since discontinued their use.
Failure to Develop Complete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan addressing the immediate needs of a newly admitted resident. The resident was admitted from the hospital with diagnoses including hypertensive chronic kidney disease with stage 5 chronic kidney disease and dependence on renal dialysis. Upon review, the baseline care plan for the resident, created the day after admission, was found to have the focus area of dialysis left blank. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Update Care Plan for Resident's Smoking Needs
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect the current needs of a resident with severe cognitive impairment, as indicated by a BIMS score of 5 out of 15. The resident was known to smoke regularly, and a safe smoking assessment required the use of a smoking apron. However, the care plan did not include goals and interventions related to tobacco use. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan had not been updated to address the resident's smoking habits. The facility's Resident Smoking Policy mandates that all safe smoking measures be documented in each resident's care plan and communicated to staff, visitors, and volunteers responsible for supervising residents while smoking. Despite this policy, the care plan for the resident in question did not reflect these requirements, leading to a deficiency in care planning for the resident's smoking needs.
Failure to Conduct Safe Smoking Assessment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who began smoking after admission. The resident, who was cognitively intact with a BIMS score of 15, was initially assessed as a non-smoker during the admission process. However, observations showed the resident smoking in the designated outdoor area under staff supervision. Despite the resident's new smoking habit, a safe smoking assessment was not completed, as confirmed by an interview with the DON. The facility's policy requires that all residents who smoke be assessed for safety and supervision needs, and these measures should be documented in the resident's care plan. This procedure was not followed, leading to the deficiency.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal immunization according to CDC recommendations. The resident, who is [AGE] years old, had previously received the Prevnar 23 vaccine and had signed a consent form to receive the PCV20 vaccine. However, there was no evidence in the medical record that the PCV20 vaccine was administered. An interview with the infection preventionist revealed that the resident had not been given the PCV15 or PCV20 vaccine due to an oversight. The facility's Pneumococcal Vaccine policy, dated 9/8/23, states that the type of pneumococcal vaccine offered will depend on the recipient's age and susceptibility to pneumonia, in accordance with CDC guidelines. According to the CDC's Adult Immunization Schedule, individuals 65 or older who have only received the PPSV23 vaccine should be administered either the PCV15 or PCV20 at least one year after the PPSV23 dose. This oversight led to the resident not receiving the recommended vaccination.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure the daily staff posting was updated daily, as required. On 6/23/24, an observation at 1:34 PM revealed that the staff posting by the main entrance was dated 6/20/24, indicating it had not been updated for three days. Later that day, at 5:30 PM, the posting was changed to reflect the current date. An interview with the nursing home administrator confirmed that the update had been made recently to reflect the current day's information. Further investigation revealed that the scheduler, who was normally responsible for updating the daily staff posting, did not work on weekends and had not updated the posting on Friday, 6/21/24, because she was working on the floor. The scheduler was unaware of who was responsible for updating the posting on weekends. An interview with the Director of Nursing (DON) clarified that it was the responsibility of the manager on duty to update the daily staff posting during weekends.
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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