Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shepherd Of The Valley Rehabilitation And Wellness during CMS and state inspections, most recent first.
Failure to protect a resident from abuse by another resident. A CNA observed one resident hit another resident in the face with a closed fist, and the injured resident had facial redness and an abrasion near the eye. The injured resident had severe cognitive impairment, dementia, depression, psychotic disorder, and wandering behaviors, while the other resident had moderate cognitive impairment, severe depression, schizophrenia, and a history of TBI. Staff interviews confirmed the injured resident was scared, skittish, and afraid for safety after the incident.
Failure to Provide Individualized Activity Programming: Three residents with dementia or other significant cognitive impairment had documented activity preferences, but staff did not consistently provide or reapproach activities to match those interests. One resident was observed in-room for long periods without activities being offered, another had limited activity participation despite stated preferences for reading, news, and outdoor time, and a third had no evidence of activity participation and the resident representative reported no invitations to activities. COTA input confirmed the facility lacked an activity director and did not facilitate independent activities for some residents.
Insulin pens in a rehab cart were found without open dates or with open dates beyond the 28-day use period. An RN confirmed the pens were available for resident use, and the DON stated staff were expected to date insulin when it was removed from the refrigerator and discard it when expired. Facility policy required insulin to be dated when first used.
Failure to maintain resident dignity during incomplete incontinence care. A resident with severe cognitive impairment, CVA, depression, BPH, total assist needs for toileting, dressing, and personal hygiene, and total bowel and bladder incontinence was observed in bed with pants down, a used brief under the legs, perineal area exposed, brown substance on the thigh, and the privacy curtain open while the roommate was present. RN stated it appeared care had been started and not finished, and CNA reported leaving the resident exposed for a skin check because the peri area was bleeding and hurting.
A resident was transferred to the hospital for evaluation, and the resident's representative was verbally notified of the transfer and bed-hold, but there was no evidence that written notice was provided. The representative stated the facility did not notify her of changes such as hospital transfers, new medication orders, or health status changes, and the DON confirmed the lack of written documentation.
Failure to Complete Significant Change MDS Assessment: A resident with dementia, progressive neurological conditions, and seizure disorder had an admission MDS that coded no mobility device use and independence with ADLs, but later was observed ambulating with a walker and gait belt. Quarterly MDSs still did not code walker use and showed increased ADL assistance needs, yet no comprehensive or significant change MDS had been completed. MDS coordinators said they were unaware of the walker use, believed the resident likely should not have been coded as independent, and confirmed the significant change MDS was missed.
Missing Anticoagulant Care Plan: A resident with intact cognition, hemiplegia, stroke, and a hx of venous thrombosis/embolism was receiving apixaban and had bruising noted on both arms after a hospital stay. Although the MAR/orders included q-shift anticoagulant side effect monitoring, the care plan did not include anticoagulant use or related interventions, and the DON confirmed the facility did not have an anticoagulant care plan in place.
A resident with severe cognitive impairment, bilateral extremity impairment, and total dependence for several ADLs was found in bed with pants down, a used brief under the legs, brown substance on the thigh, and the perineal area exposed while a lift sling remained in place. RN staff noted it appeared care had been started and not finished, and a CNA said the resident had been left exposed for a skin check because the peri area was bleeding and hurting. The DON stated staff were expected to check residents every 2 to 3 hours and complete care.
Failure to provide ordered tracheostomy care for a resident with a trach, pneumonia, chronic lung disease, and respiratory failure. Staff did not consistently change the disposable inner cannula as ordered, with records showing multiple missed or undocumented changes and notes that the cannula was not available. The resident reported staff were out of inner cannulas and sometimes removed, inspected, and reinstalled the cannula instead of changing it. RN and DON interviews confirmed supply shortages and that staff sometimes cleaned and reused the cannula without a physician order.
Failure to provide behavioral health services for a resident with schizophrenia and moderate cognitive impairment. The resident was receiving multiple antipsychotic meds and had a care plan for agitation, anger, cursing, grabbing, hitting, and kicking. The resident struck another resident, sending both to the ED. A PASRR Level II review recommended case management and a neurocognitive eval, but the record showed no evidence these services were provided.
A resident with severe cognitive impairment and diagnoses including Alzheimer's disease, non-Alzheimer's dementia, and seasonal allergic rhinitis did not receive ordered Sudafed for sinus congestion because the MAR showed it was on order from the pharmacy. Notes documented a productive cough and an order for Sudafed 1 tablet daily, but staff later confirmed the medication had been in the med cart, the MA-Cs did not see it, and the resident missed doses.
A resident with severe cognitive impairment and an indwelling urinary catheter was on EBP per the care plan, but staff did not use the required gown and other PPE during catheter care. A CNA drained the catheter bag using gloves and hand sanitizer only, and an MA-C stated she did not wear a gown for urinary catheter care even though PPE was available outside the room. The IP confirmed that residents with urinary catheters were on EBP and that gown, gloves, and face shield or goggles should be worn for catheter care.
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.
A resident with moderately impaired cognition, dementia, depression, cancer, identified fall risk, and risk for skin breakdown was care planned to have the call light kept within reach, but surveyors observed the resident seated in a recliner with the call light out of reach on multiple occasions. The resident did not know where the call light was, had a wet brief, and could not request assistance, which was also confirmed by the resident’s representative, who noted the resident was covered with a blanket and not wearing pants underneath. A guest ultimately activated the call light, after which a CNA responded and removed soiled linens. The DON stated staff are expected to ensure residents have access to the call light and needed items when left alone, while the NHA acknowledged there was no facility policy on call light use.
A resident with severe cognitive impairment and wandering behaviors entered another resident's room and was physically struck in the nose, resulting in a bloody nose. The resident who struck admitted to the action, and the incident was confirmed by staff and the DON. This event demonstrates a failure to protect a resident from physical abuse by another resident.
Two residents with surgical wounds experienced deficiencies in physician notification and timely implementation of treatment orders. One resident suffered actual harm and required additional surgery after the facility discontinued a wound vac without notifying the orthopedic surgeon. Another resident experienced a delay in wound care and antibiotic therapy due to failure to update physician orders, with the physician not notified of the delay. The facility did not follow its own policy for physician notification and timely care.
Three residents experienced deficiencies in care, including delayed wound assessment and treatment, failure to promptly implement physician orders for wound care and antibiotics, and inadequate neurological monitoring after a fall. One resident was hospitalized for sepsis after a wound worsened without timely intervention or family notification, another had a delay in starting prescribed wound care and antibiotics, and a third did not receive required neuro checks after a fall resulting in a nasal fracture.
A resident with a surgical wound and infection did not receive wound vac care as ordered by the surgeon. The wound vac was discontinued by facility staff without notifying the surgeon, leading to wound deterioration and the need for additional surgical intervention. Documentation showed improper wound vac application and lack of timely communication with the surgical team.
The facility failed to meet the activity needs of four residents, who expressed desires for specific activities but were not adequately informed or engaged. Residents participated minimally in independent activities, with limited group activity involvement due to staffing shortages and unappealing options.
The facility experienced staffing shortages, leading to unmet care needs and incomplete restorative programs for residents. Interviews revealed high CNA turnover and delayed responses to call lights. Discrepancies in bathing records were found, with showers documented by the DON not supported by bath schedule logs. The lack of restorative nursing was due to staff being reassigned to cover open shifts, and the East Station Bath Schedule logs were not part of official records.
The facility failed to identify and monitor target symptoms for residents receiving psychotropic medications. A resident with severe cognitive impairment and multiple diagnoses was on several psychotropic drugs without evidence of monitoring for effectiveness. This issue was also found in other residents with similar conditions, indicating a pattern of non-compliance with the facility's policy on psychotropic drug use.
The facility failed to label and date insulin pens in two medication storage areas. Observations revealed several opened insulin pens without dates. Interviews with an RN and the DON confirmed the requirement for labeling opened insulin pens. The facility's policy mandates dating multi-dose vials upon opening and discarding them within 28 days unless specified otherwise.
The facility failed to accurately document bathing records for three residents, leading to discrepancies between initial and updated records. Interviews revealed that the system was updated with information from bath schedule logs after records were requested, and the responsible staff member was no longer employed. The administrator confirmed that these logs were not part of official records, highlighting a deficiency in documentation practices.
The facility failed to provide consistent restorative nursing care to two residents, leading to a decline in their ability to perform activities of daily living. One resident, who was cognitively intact, reported a decline in mobility due to the lack of restorative care, while another resident with severe cognitive impairment experienced inconsistent delivery of restorative programs. The deficiency was attributed to staffing shortages, with restorative aides being reassigned to cover open shifts.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastric tube. An RN was observed providing high-contact care without wearing a gown, despite EBP signage indicating the need for gowns and gloves. Staff interviews revealed a lack of awareness about EBP requirements, and the facility's policy, which mandates gowns and gloves for high-contact care, was not adhered to.
A resident with severely impaired cognitive skills and non-Alzheimer's dementia was physically abused by another resident with moderate impairment and a history of violent comments. The altercation resulted in the victim sustaining a nasal bone fracture after being punched in the face. The incident was witnessed by a CNA student, highlighting a failure to enforce the facility's abuse prevention policy.
A resident with moderate cognitive impairment and a history of making violent comments was involved in two physical altercations with another resident, resulting in injury. The care plan was updated to include distraction techniques but failed to address the resident's physical aggression, as confirmed by the DON.
A resident with acute respiratory symptoms was not tested for COVID-19 despite exhibiting symptoms and the presence of COVID-19 in the facility. Staff interviews revealed a failure to adhere to infection prevention protocols, as the resident's representative had to bring a test from outside to confirm the infection. The facility's policy required immediate testing for respiratory symptoms, but this was not followed.
A resident with moderate cognitive impairment and enteritis experienced multiple episodes of vomiting and dehydration, but the facility failed to notify the physician or reassess the condition promptly. The resident was transported to the hospital via facility van without healthcare staff, leading to a collapse and death in the emergency room waiting area.
Failure to Protect a Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to ensure a resident was free from abuse by another resident. Resident #37 had severe cognitive impairment with a BIMS score of 3 out of 15 and diagnoses including non-Alzheimer’s dementia, depression, psychotic disorder, and daily wandering behaviors. Resident #13 had moderate cognitive impairment with a BIMS score of 10 out of 15, a PHQ-9 score of 24 indicating severe depression, and diagnoses including schizophrenia and a personal history of traumatic brain injury. An incident report documented that a CNA observed resident #13 hit resident #37 on the left side of the face, and both residents were sent to the ED. A progress note described redness and an abrasion on the left side of resident #37’s face near the eye, with additional reddened areas on the left cheekbone. Interviews with the resident’s representative, CNA, LPN, and RN indicated resident #37 was scared, skittish, quiet, stoic, and afraid for safety after the incident, and staff confirmed resident #13 punched resident #37 multiple times with a closed fist.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to ensure individual activities were provided to meet the interests and support the physical, mental, and psychosocial well-being of 3 residents reviewed for activity participation. Resident #34 had diagnoses including non-Alzheimer's dementia and depression, and the annual MDS showed the resident valued going outside for fresh air, reading books, newspapers, and magazines, being around animals, keeping up with the news, and doing favorite activities. The activity care plan listed interests such as animals, board games, volunteering, dining out, movies, spending time outdoors, listening to the radio, watching sports, and TV, but the resident representative stated staff offered activities and did not reapproach after refusals. Continuous observation showed resident #34 remained in the room in a recliner for extended periods on 7/29/26 without activities being offered, despite scheduled activities that day including daily chronicle, fun with fitness, reading time, treats, music, and reading/trivia. The activity participation record showed the resident was offered activities 115 times from 4/28/26 through 7/29/26, mostly independent activities, with 52 refusals documented. COTA #1 stated the facility did not have an activity director, she did not perform activities daily, and the facility did not facilitate independent activities for resident #34 or resident #123. Resident #123 had a BIMS score of 8/15, indicating moderate cognitive impairment, and diagnoses including progressive neurological conditions, non-Alzheimer's dementia, and seizure disorder or epilepsy. The resident stated it was very important to read books, newspapers, and magazines, keep up with the news, and go outside for fresh air, and the care plan listed preferred activities such as arts and crafts, ceramics, visiting with others, shuffleboard, sports, TV, movies, listening to oldies, and being outdoors. The activity participation record showed 75 activity offers with 10 refusals. Resident #178 had a BIMS score of 3/15, severe cognitive impairment, and diagnoses including nontraumatic intracerebral hemorrhage and macular degeneration; the resident preferred animals, music, favorite activities, and going outdoors, but observations and the resident representative indicated the resident did not participate in group or individual activities, had not been invited to activities, and had no activity calendar in the room. The record showed no evidence of activity participation.
Insulin Pens in Rehab Cart Were Undated or Kept Past Open Dating
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when insulin medications in rehabilitation unit cart A were found without required open dates or with expired open dates. During observation of the cart with RN #1, insulin glargine-yfgn 100 units/mL pens were present with an open date 30 days prior to the observation and another pen had no open date, and insulin lispro KwikPens 100 units/mL were present with an open date 48 days prior to the observation and another pen had no open date. RN #1 stated the insulin pens were good for 28 days and confirmed the medications were available for resident use. The DON stated staff were expected to date insulin when it was removed from the refrigerator and made available for use, and to discard insulin when it expired. Facility policy stated insulin products should be stored in the refrigerator until opened and that the date should be noted on insulin vials and pens when first used.
Failure to Maintain Resident Dignity During Incomplete Incontinence Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity and to care for the resident in a manner and environment that promoted maintenance or enhancement of quality of life. The resident had a significant change MDS showing a BIMS score of 5, severe cognitive impairment, diagnoses including CVA, depression, and BPH, bilateral impairment of the upper and lower extremities, total assistance needs for toileting, dressing, and substantial/maximal assistance for personal hygiene, and was always incontinent of bowel and bladder. The care plan identified impaired balance and dependence for bed mobility, dressing, and personal hygiene. During observation, the resident was found lying in bed with pants pulled down around the ankles, a used brief rolled up under the upper legs, brown substance on the left upper thigh, and the perineal area exposed while the lift sling remained under the resident, the mechanical lift was beside the bed, the bed was elevated, and the privacy curtain was open with the roommate present. RN #3 stated it appeared someone had been changing the resident and got called away without finishing. CNA #1 stated he had placed the resident in bed with the brief tucked under the resident and left the resident exposed for a skin check because the peri area was bleeding and hurting. The DON stated staff were expected to check residents every 2-3 hours and finish providing care, and also stated the facility did not have a policy related to turning, repositioning, or checking residents.
Failure to Provide Written Transfer and Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written notice of transfer and bed-hold for resident #34 when the resident was transferred non-emergently to the hospital for evaluation. A progress note dated 11/20/25 at 12:48 PM documented the transfer, and a transfer notice showed the resident's representative was verbally notified of the transfer, but there was no evidence that the transfer notice was provided in writing. A Bed Hold Agreement dated 11/20/25 showed the resident was verbally notified of the bed hold, but there was no evidence the resident's representative was notified in writing. The resident representative stated the facility did not notify her of changes such as hospital transfers, new medication orders, or health status changes, and the DON confirmed there was no evidence that written notice for the transfer or bed-hold had been provided.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change MDS assessment for a resident with a history of progressive neurological conditions, non-Alzheimer's dementia, and seizure disorder or epilepsy. The admission MDS showed a BIMS score of 8 out of 15, no upper or lower range of motion impairment, no use of mobility devices, and independence or set-up/clean-up help only for all ADLs. However, observation later showed the resident ambulating with a walker and wearing a gait belt, which differed from the admission assessment and from subsequent quarterly MDS assessments. The quarterly MDS assessments also did not code the resident as using a walker and showed increased assistance needs, including partial/moderate assistance with oral hygiene, personal hygiene, showering/bathing, and toileting hygiene, as well as supervision or touching assistance with some other ADLs. Review of the completed MDS assessments showed no comprehensive MDS, including a significant change assessment, had been completed since admission. MDS coordinators stated they were not aware the resident was using a walker, believed the resident probably should not have been coded as independent for ADLs on the admission MDS, and confirmed that a significant change MDS should have been completed but had not been.
Missing Anticoagulant Care Plan
Penalty
Summary
Failure to develop and implement a comprehensive person-centered care plan was identified for resident #7. The resident had a significant change MDS dated 5/19/25 with a BIMS score of 14/15, indicating intact cognition, and diagnoses including hemiplegia, stroke, and a history of venous thrombosis and embolism. The resident was receiving apixaban 5 mg by mouth twice daily, and the physician orders included anticoagulant medication side effect monitoring each shift for bleeding, bruising, black tarry stools, red urine, sudden severe headache, and nausea/vomiting, with instructions to document findings in progress notes and notify the medical provider. On 7/28/26, bruises were observed on both lower arms, and the resident stated the bruising occurred at the hospital and that he/she was on an anticoagulant. A progress note dated 7/24/26 documented that the resident had been readmitted from the hospital with scattered bruising to both arms from IV starts and blood draws. Review of the care plan did not show anticoagulant use or related interventions, and the DON confirmed on 7/30/26 that the facility did not have an anticoagulant care plan for the resident until one was formatted that day.
Delayed ADL Care and Incomplete Perineal Assistance
Penalty
Summary
The facility failed to ensure necessary ADL care was provided timely for a resident with severe cognitive impairment and significant functional dependence. The resident had a BIMS score of 5 out of 15, diagnoses including cerebrovascular accident, depression, and benign prostatic hyperplasia, bilateral impairment of the upper and lower extremities, and required total assistance for toileting, upper and lower body dressing, footwear, and substantial/maximal assistance for personal hygiene. The resident was also always incontinent of bowel and bladder, and the care plan identified impaired balance, dependence for dressing, and substantial/maximal assistance for personal hygiene. On observation, the resident was found lying in bed with pants pulled down around the ankles, a used brief rolled up under the upper legs, brown substance on the left upper thigh, and the perineal area exposed while a mechanical lift sling remained under the resident and the privacy curtain was open. RN #3 observed that it appeared someone had started changing the resident and then left before finishing. CNA #1 stated he had placed the resident in bed with the brief tucked under him/her and left the resident exposed for a skin check because the peri area was bleeding and hurting, while the DON stated staff were expected to check residents every 2 to 3 hours and finish providing care.
Failure to Provide Ordered Tracheostomy Care
Penalty
Summary
The facility failed to provide ordered respiratory care for a resident with a tracheostomy. The resident had a BIMS score of 15 out of 15 and diagnoses that included pneumonia, anxiety disorder, chronic lung disease, and respiratory failure. The medical record showed a recent hospital admission for sepsis due to pneumonia, and discharge instructions and physician orders included daily and PRN tracheostomy care with a disposable inner cannula change every day. Resident interview indicated staff were not changing the inner tracheostomy cannula daily and that the facility had been out of inner cannulas. The resident stated that when no inner cannula was available, staff sometimes removed it, inspected it, and reinstalled it, and that cleaning had been discussed but not observed. The TAR and progress notes showed multiple dates when the inner cannula change was not documented and the cannula was documented as not available. RN #1 stated the facility had only one inner cannula available, reserved for emergencies, and that staff would remove and assess or clean and reuse the cannula when supplies were unavailable. The DON stated the expectation was daily change per physician order and confirmed no physician order existed to clean the inner cannula if none were available. The facility policy on tracheostomy care directed staff to remove the inner cannula, place it in hydrogen peroxide, clean it, rinse it, and replace it.
Failure to Provide Behavioral Health Services for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure behavioral health services were provided to a resident with schizophrenia and moderate cognitive impairment, as shown by a BIMS score of 10 out of 15. The resident’s MAR showed treatment with multiple antipsychotic medications, including haloperidol, clozapine, and aripiprazole. The care plan identified impaired psychosocial well-being with behaviors requiring intervention, including agitation, anger, cursing, grabbing, hitting, and kicking, and listed interventions such as redirection, removal from the situation, meaningful activity, reapproach, and one-to-one supervision. A facility incident report showed the resident struck another resident on the left side of the face, and both residents were assessed and sent to the ED. The resident’s PASRR Level II review recommended case management and a neurocognitive evaluation, but the medical record showed no evidence that either a neurocognitive evaluation or mental health services were provided. A social services assistant stated that she and another assistant checked on the resident a couple of times a day, especially when the resident had behaviors, and confirmed the resident had not received a neurocognitive evaluation upon admission and did not receive case management services.
Medication Not Given as Ordered
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of resident #65 when the resident did not receive Sudafed Sinus Congestion Oral Tablet as ordered for sinus congestion. The resident had a quarterly MDS assessment showing a BIMS score of 5 out of 15, indicating severe cognitive impairment, and diagnoses including Alzheimer's disease, non-Alzheimer's dementia, and seasonal allergic rhinitis. Physician orders directed the resident to receive Sudafed Sinus Congestion Oral Tablet once daily, but the MAR showed the medication was not administered on 6/28/26 and 6/29/26 because it was on order from the pharmacy. A progress note on 6/28/26 documented a productive cough, and a progress note on 6/29/26 documented Sudafed Sinus Congestion Oral Tablet 1 tablet by mouth one time a day for sinus congestion with a note that it may be discontinued when symptoms resolve. The DON stated her expectation was for nursing staff to check and verify the medication was not in backup, and further interview confirmed the medication had been in the medication cart, the MA-Cs did not see it, and the resident did not receive the Sudafed on the identified days.
Failure to Use Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one sampled resident with an indwelling urinary catheter. The resident had a BIMS score of 3 out of 15, indicating severe cognitive impairment, and diagnoses that included non-traumatic brain dysfunction, cerebrovascular accident, and non-traumatic intracerebral hemorrhage. The resident also required supervision for personal hygiene and had a care plan for a foley catheter that stated CDC guidelines for enhanced barrier precautions would be followed by personnel. During observation, a CNA applied hand sanitizer, donned gloves, drained urine from the catheter bag, and wiped the end of the drainage tubing with an alcohol wipe, but no additional PPE was used during the catheter care. An Enhanced Barrier Precautions sign and a PPE cart were present outside the resident’s room. In interview, the MA-C stated she did not wear a gown when providing urinary catheter care, although she knew gowns and other PPE were available outside the room. The infection preventionist stated that all residents with urinary catheters were on enhanced barrier precautions and that a gown, gloves, and face shield or goggles should be worn when providing catheter care. The facility policy stated that EBP involve gowns and gloves during high-contact care activities, including emptying drainage bags.
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.
Failure to Ensure Call Light Accessibility and Supervision for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent accidents for one resident with moderately impaired cognition and multiple diagnoses, including non-Alzheimer’s dementia, depression, and cancer. The admission MDS showed a BIMS score of 12/15 and the care plan, last revised on 11/19/25, identified the resident as a moderate fall risk related to confusion, gait and balance problems, and psychoactive drug use, with an intervention initiated on 11/25/24 to ensure the call light was within reach. A Braden Scale assessment on 1/2/26 scored the resident at 16/23, indicating risk for skin breakdown. Despite these identified needs and care plan interventions, observations on 1/28/26 at 9:55 AM and 10:35 AM showed the resident seated in a recliner at the foot of the bed with the call light located at the head of the bed and not within reach, while the resident’s lower body was covered with a blanket. Further observations and interviews on 1/28/26 showed the resident did not know where the call light was and stated it “should be around here somewhere.” At 11:33 AM, the resident’s brief was confirmed to be wet, and the resident reported being unable to request assistance because the call light was not accessible. The resident’s representative also observed that the resident’s brief was wet, the resident was covered with a blanket without pants underneath, and the call light had not been within reach to request help. At 11:48 AM, the call light was activated by the resident’s guest, and at 11:53 AM a CNA answered the call light, closed the door, left the room, returned with a clean blanket, and exited at 12:04 PM with two bags of soiled linens. The DON later confirmed that staff are expected, when leaving a resident alone, to set the resident up with the call light and other needs and perform hand hygiene, and the NHA reported that the facility did not have a policy on call light use.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment, wandering behaviors, and diagnoses including encephalopathy and agitation was involved in an incident where they entered another resident's room in the memory care unit. The resident whose room was entered asked the wandering resident to leave, and when this did not occur, physically struck the wandering resident in the nose, resulting in a bloody nose. The incident was documented in the facility's records, and the resident who was struck was able to stop the bleeding on their own. Interviews confirmed that the resident who struck the other admitted to the action, and the event was reported to the affected resident's representative. Staff interviews revealed that the assessment following the altercation confirmed the physical injury and emotional impact on the resident who was struck. The incident was also confirmed by the DON, who acknowledged the physical altercation and resulting injury. The deficiency centers on the facility's failure to protect a resident from physical abuse by another resident, as required by regulations.
Failure to Notify Physicians of Changes in Condition and Treatment Orders for Residents with Surgical Wounds
Penalty
Summary
The facility failed to notify physicians of changes in condition or treatment for two residents with surgical wounds, resulting in actual harm to one resident. For the first resident, who was cognitively intact and had a complex right elbow surgical wound with infection, the wound vac order was discontinued by the facility's wound nurse without notifying the orthopedic surgeon. The resident subsequently presented to the clinic without the wound vac in place, leading to exposure and deterioration of the triceps tendon, and required additional surgical intervention. Documentation showed that the facility's PA-C and nursing staff communicated with the clinic only after the wound had worsened, and the orthopedic surgeon confirmed that the lack of notification and discontinuation of the wound vac led to the need for further surgery. For the second resident, who had moderate cognitive impairment and a surgical wound on the right tibia, there was a delay in initiating physician-ordered wound care and antibiotic therapy. Orders for wound care and Keflex were written and noted in the medical record, but the treatments were not started until several days later. The DON confirmed that the nurse failed to update the physician orders in a timely manner, and the orthopedic surgeon was not notified of the delay in starting the prescribed treatments. A review of the facility's skin integrity policy indicated that licensed nurses are required to notify physicians and resident representatives of changes in wound condition or new treatment orders. The policy also requires weekly wound evaluations and prompt notification if a wound fails to improve or deteriorates. In both cases, the facility did not follow its own policy regarding physician notification and timely implementation of treatment orders, resulting in harm and delayed care for the affected residents.
Failure to Provide Timely and Appropriate Care, Wound Management, and Post-Fall Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. One cognitively intact resident with diabetes, neuropathy, and renal insufficiency was at risk for pressure ulcers and developed a right buttock wound with increased depth, yellow/green slough, and foul odor. Despite documentation of these changes, there was a lack of timely follow-up notes regarding the wound or possible infection for several days. The resident's family was not notified of the wound's severity until the resident was hospitalized for sepsis, and the representative reported that the resident should have been sent to the hospital sooner. Another resident with moderate cognitive impairment and a surgical wound had physician orders for wound care and antibiotics that were not implemented until five days after the orders were written. The delay was discovered by the facility, and the orthopedic surgeon was not notified of the delay in starting the prescribed treatments. This lapse resulted from the nurse's failure to update the physician orders in a timely manner. A third resident with severe cognitive impairment and a high risk for falls experienced an unwitnessed fall, after which only one neurological assessment was documented, despite facility protocol requiring more frequent checks. The resident later presented with bruising and an abrasion, and a CT scan revealed a nondisplaced acute nasal bone fracture. The DON was unable to account for the missing neurological assessment records, and the facility's policy for post-fall monitoring was not followed.
Failure to Follow Wound Vac Orders and Notify Surgeon Resulting in Harm
Penalty
Summary
A resident with a history of a right elbow fracture, surgical wound, and wound infection, including methicillin-resistant Staphylococcus aureus (MRSA), was admitted with a surgical wound requiring a wound vac as ordered by the orthopedic surgeon. The care plan included dressing changes as ordered, and the medication administration record indicated wound vac changes were scheduled three times weekly. However, the wound vac order was discontinued by the facility's provider after the wound nurse reported it was not applied, without notifying the orthopedic surgeon who had placed the original order. There was no evidence that the surgeon was consulted prior to discontinuing the wound vac. Subsequently, the resident was seen in clinic without the wound vac in place, and the triceps tendon was exposed and developing eschar, prompting a recommendation for further surgical intervention. Progress notes documented that the wound vac dressing was found improperly applied, causing the wound to be dry and the tendon frayed. The facility's provider and wound care nurse decided not to reapply the wound vac, and only after further communication with the clinic was a follow-up appointment and a skin graft consult arranged. The orthopedic surgeon confirmed that the resident required additional surgeries due to the facility's failure to follow the wound vac order and to notify the surgeon of changes.
Failure to Meet Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that activities met the interests and needs of four residents, as identified in the report. Resident #30, who was cognitively intact and had an amputation, expressed a desire to go outside and listen to music. However, the resident was unaware of available group activities and participated minimally in independent activities. The activity director acknowledged that activity aides should inform residents about activities upon admission. Resident #61, with moderate cognitive impairment and conditions including depression and phantom limb syndrome, expressed an interest in playing BINGO. Despite this, the resident's participation was limited to independent activities, with no recorded participation in BINGO. Similarly, Resident #41, who was cognitively intact and had multiple diagnoses, expressed a desire for more engaging activities. The resident participated in some independent activities but did not engage in group activities due to a lack of interest and the facility's limited ability to organize outings. Resident #22, also cognitively intact, had a range of interests including reading, music, and outdoor activities. However, the resident found the facility's activities unappealing and participated only in independent activities. The activity director noted that the facility had been understaffed, affecting their ability to offer diverse activities and outings. The director also mentioned efforts to hire additional staff and assess residents' activity preferences.
Staffing Shortages and Documentation Issues in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, affecting two of the five resident care units. Interviews with residents during a council meeting revealed issues such as high turnover of CNAs, delayed response to call lights, unmade beds, and untidy rooms. Several residents expressed concerns about the lack of staff, with one resident specifically mentioning a decline in their ability to transfer due to insufficient restorative nursing care. This resident's restorative nursing plan was not being followed because restorative staff were reassigned to cover open shifts. The documentation review revealed discrepancies in the bathing records for multiple residents. For instance, one resident's bathing record initially showed no showers for a period, but was later updated by the DON to reflect showers that were not documented in the East Station Bath Schedule logs. Similar inconsistencies were found in the records of other residents, where showers were documented by the DON but not supported by the bath schedule logs. These discrepancies indicate a lack of proper documentation and verification of care provided. Interviews with the DON, MDS coordinator, administrator, and regional clinical director confirmed that the lack of restorative nursing was due to staff being pulled to cover other duties. Additionally, the East Station Bath Schedule logs were not considered part of the official resident records, leading to further inconsistencies in documentation. The facility's failure to maintain accurate records and provide adequate staffing resulted in unmet care needs and incomplete restorative programs for residents.
Failure to Identify and Monitor Target Symptoms for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for five residents who were receiving psychotropic medications. Resident #45, with severe cognitive impairment and multiple diagnoses including non-Alzheimer's dementia and anxiety disorder, was receiving several psychotropic medications such as Ativan, bupropion, buspirone, sertraline, and trazadone. However, there was no evidence in the physician orders or care plan that the facility had identified or was monitoring specific target symptoms to evaluate the effectiveness of these medications. Similarly, Resident #96, who was cognitively intact but had diagnoses including non-Alzheimer's dementia and depression, was receiving quetiapine and sertraline. The facility again failed to identify or monitor specific target symptoms for these medications. This pattern was repeated with Resident #120, who had severe cognitive impairment and was receiving escitalopram, olanzapine, and divalproex, as well as Resident #72 and Resident #114, both of whom had severe cognitive impairments and were on various psychotropic medications without identified target symptoms. The facility's policy on psychotropic drugs, last updated in October 2022, states that the Interdisciplinary Team (IDT) should validate appropriate diagnoses of behavioral symptoms and evaluate the resident's medication regime to avoid duplicate drug therapy. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of target symptoms and monitoring for the effectiveness of psychotropic medications in the residents' care plans and physician orders.
Failure to Label and Date Insulin Pens
Penalty
Summary
The facility failed to properly label and date medications in two of six medication storage areas, specifically on the South Hall medication carts #1 and #2. During an observation, it was found that several insulin pens, including Lantus Solostar, Novolog Insulin Aspart, and Humalog, were opened but not dated. Interviews with a registered nurse (RN) and the Director of Nursing (DON) confirmed that insulin pens should be labeled with the date they were opened, and that nursing staff were responsible for labeling multidose medications with the resident's name and the date of opening. A review of the facility's policy on Medication Storage and Handling indicated that multi-dose vials should be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer.
Inaccurate Documentation of Bathing Records
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for three residents regarding their bathing schedules. Resident interviews and medical record reviews revealed discrepancies in the documentation of showers received. One resident reported not receiving showers consistently due to staffing issues, and the initial 30-day bathing record showed no showers documented before a certain date. However, an updated record later showed showers documented by the DON, which were not initially recorded. Similar discrepancies were found for two other residents, where the updated records showed showers that were not documented in the original records. Interviews with the DON and MDS coordinator revealed that the system was updated with information from bath schedule logs after the records were requested, and the staff member responsible for completing these logs was no longer employed at the facility. The administrator and regional clinical director confirmed that the bath schedule logs were not part of the official resident records, and bathing was expected to be documented in the resident records when it occurred. This lack of accurate documentation led to the deficiency identified by the surveyors.
Inadequate Restorative Nursing Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative nursing care to maintain the ability of residents to perform activities of daily living. Resident #22, who was cognitively intact and had functional limitations in range of motion, reported a decline in mobility and the need for a full body mechanical lift due to the lack of restorative care. Despite having an active restorative nursing plan, the resident's programs were inconsistently provided, with only a few sessions documented over several months. The resident expressed a desire to participate in restorative care but was informed that staffing shortages were preventing the implementation of the plan. Resident #100, who had severe cognitive impairment and no range of motion impairment, also experienced inconsistent delivery of restorative programs. The resident's scheduled activities were sporadically provided, with significant gaps between sessions. Interviews with the Director of Nursing and MDS coordinator confirmed that the lack of restorative nursing was due to restorative aides being reassigned to cover open shifts on the floor. The facility's policy indicated that residents at risk of functional decline should receive restorative care, but this was not adhered to in practice.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control procedures for a resident under Enhanced Barrier Precautions (EBP). During an observation, a stop sign indicating EBP was posted on the resident's room door, but the registered nurse (RN) did not adhere to the required precautions. The RN was observed wearing gloves but no gown while providing high-contact care, including removing a gastric tube dressing and assisting in repositioning the resident. The RN admitted that gowns were supposed to be worn for such care but were not available in the room at the time. Interviews with staff revealed a lack of awareness and understanding of the EBP requirements. A certified nursing assistant (CNA) stated she was unaware of the need to wear gowns until the day before the interview. The infection preventionists confirmed that EBP required gowns and gloves for high-contact care involving residents with medical devices like feeding tubes. The facility's policy on EBP, last revised in March, outlined the necessity of using gowns and gloves to prevent the transfer of multi-drug resistant organisms, but this was not followed in practice.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. Resident #1, who had severely impaired cognitive skills and a diagnosis of non-Alzheimer's dementia, was involved in an altercation with Resident #2. Resident #2, with a BIMS score indicating moderate impairment and a history of making violent comments, punched Resident #1 in the face after a confrontation in the hallway. This incident led to Resident #1 sustaining a nasal bone fracture and being taken to the hospital. The altercation occurred after Resident #1 approached Resident #2 and engaged in behavior that led to a physical confrontation. Despite Resident #2's history of making comments about past violence, the facility did not prevent the escalation that resulted in physical harm. The incident was witnessed by a CNA student, and the facility's policy on abuse, which defines physical abuse as including punching, was not effectively enforced to prevent the incident.
Failure to Address Physical Aggression in Resident Care Plan
Penalty
Summary
The facility failed to develop an individualized, comprehensive care plan for a resident with a history of traumatic brain injury and non-Alzheimer's dementia, who exhibited moderate cognitive impairment. The resident had a documented behavior problem of making comments about past violence towards women, although they would laugh and claim they would never act on these comments. Despite this, the care plan did not address potential or actual physical aggression, which became evident in two separate incidents involving physical altercations with another resident. In the first incident, the resident was involved in a shoving match with another resident after a verbal exchange, although no injuries were reported. In a subsequent incident, the resident punched the other resident in the face, resulting in a nasal bone fracture for the victim. The care plan was updated to include an intervention to engage the resident in conversation as a distraction when anxious, but it still failed to address the resident's physical aggression. The Director of Nursing confirmed that the care plan did not include measures for potential or actual physical aggression, highlighting a deficiency in the care planning process.
Failure to Implement Infection Prevention Protocols
Penalty
Summary
The facility failed to implement appropriate infection prevention interventions for a resident with acute respiratory symptoms. The resident, who was cognitively intact and had a history of atrial fibrillation, morbid obesity, diaphragmatic hernia, and obstructive sleep apnea, reported feeling unwell with symptoms such as weakness and a runny nose for several days before testing positive for COVID-19. Despite the resident's complaints and the presence of COVID-19 in the facility, staff did not test the resident for COVID-19, and the resident's representative had to bring a test from outside, which confirmed the infection. Interviews with staff revealed a lack of adherence to the facility's infection prevention protocols. RN #1 stated that nurses should follow up with the doctor and infection prevention staff regarding testing if residents exhibit COVID-19 symptoms. However, RN #2 admitted to not contacting the physician or performing COVID-19 testing, as the resident seemed to feel better. The facility's policy required immediate testing for residents showing respiratory symptoms, but this was not followed in the case of the resident. The infection preventionist confirmed that staff were expected to notify the infection prevention team and the physician for a COVID-19 order if a resident exhibited respiratory symptoms. The administrator and DON also indicated that nurses should monitor symptoms and notify the infection preventionist and doctor if symptoms worsen. Despite these protocols, the facility did not test the resident as required, leading to a deficiency in infection prevention and control.
Failure to Provide Timely Assessment and Treatment Leads to Resident Harm
Penalty
Summary
The facility failed to ensure timely assessment and treatment for a resident with a change of condition, resulting in actual harm. The resident, who had moderate cognitive impairment and required assistance with daily activities, was on antiplatelet therapy and had been prescribed anti-emetic medications for enteritis. Despite showing signs of dehydration and experiencing nausea and vomiting, the facility did not notify the physician promptly or reassess the resident's condition adequately. The resident experienced multiple episodes of vomiting and refused meals, yet there was no evidence of physician notification or reassessment of the resident's condition. The facility's staff did not consider the resident's condition critical, and the resident was transported to the hospital via the facility van without a healthcare staff member accompanying them. The resident's family had expressed concerns about the resident's condition, but the facility delayed contacting the physician and arranging for hospital transport. The resident was eventually taken to the emergency room after significant delays, during which time their condition worsened. The resident was left in the emergency department waiting area without facility staff, and subsequently collapsed and passed away. Interviews with facility staff revealed a lack of urgency in responding to the resident's condition and a failure to follow standard procedures for transporting unstable residents.
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Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Casper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Casper | 3.1 mi | ★★★★★ | 16 | 1 |
| Casper Mountain Rehabilitation And Care Center | 3.2 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.