Summit Ridge Skilled Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Douglas, Wyoming.
- Location
- 1108 Birch Street, Douglas, Wyoming 82633
- CMS Provider Number
- 535040
- Inspections on file
- 21
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Summit Ridge Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment experienced physical abuse from another resident, resulting in visible injuries. In one case, a resident was grabbed by the arm during a meal, and in another, a resident was slapped in their room. Both incidents were confirmed by staff observations and facility investigations, indicating a failure to prevent resident-to-resident abuse.
A resident who required assistance with bathing due to physical limitations was not provided or offered scheduled showers for multiple extended periods, despite facility policy and a care plan indicating the need for regular hygiene support. Documentation was lacking for these missed showers, and both the resident and their representative reported lapses in bathing care.
The facility failed to ensure two residents received their $50 personal needs allowance, as SSA payments were used to pay the facility, leaving no balance for personal use. The former administrator confirmed that personal funds were used to pay down debts owed to the facility.
A resident with memory issues was struck by another resident in the dining area, while staff were unaware due to their backs being turned. The aggressor had a history of aggression, yet was unsupervised, leading to the incident. Surveillance confirmed the attack was unprovoked.
The facility did not adhere to its policy for timely reporting of suspected abuse, neglect, or theft. Two resident-to-resident altercations were reported to facility administration promptly but were not reported to the state survey agency within the required timeframe. Interviews with the former and current administrators and the social service director confirmed the delay in reporting.
The facility failed to provide necessary behavioral health care to residents with dementia, resulting in harm to a resident who exhibited aggressive behaviors and another who expressed suicidal ideations. Despite orders for psychological evaluations and care plans, there was a lack of effective interventions and documentation. Staff interviews revealed gaps in communication and documentation, contributing to unmet needs and potential harm.
The facility failed to document 24-hour nursing coverage, as required. On several occasions, the PBJ Staffing Data Report showed gaps in coverage, with the DON working 12-hour shifts but no documentation for the remaining hours. The NHA noted issues with the payroll system preventing proper clock-in for the salaried DON, leading to the deficiency.
The facility did not ensure the dietary manager met the necessary qualifications, as she had not completed the Certified Dietary Manager coursework. The facility had a dietician on-site weekly for 8 hours, and the census was 43.
The facility did not implement a water management program as part of its IPCP to control water-borne pathogens and failed to conduct an annual review of the IPCP. Despite having a Legionella Surveillance policy, the facility did not perform primary prevention strategies. An interview with the former NHA confirmed the lack of review and documentation for the water management program.
A facility failed to complete a discharge summary for a resident discharged to a hospital. The discharge summary, which should have included a recapitulation of the resident's stay, was missing. This was confirmed during an interview with the NHA.
A facility failed to conduct regular safety evaluations of bed rails for a resident, as required by their policy. An observation revealed that the last evaluation was conducted over three years ago, despite the policy mandating annual assessments. An MDS coordinator confirmed the lack of documentation for further evaluations.
A resident with severe cognitive impairment due to alcohol-induced dementia was involved in multiple altercations, yet the facility failed to develop specific interventions or a behavioral care plan. Documentation and communication were inadequate, with no professional evaluation of the resident's behaviors and a lack of consultation with the medical director.
A facility failed to provide necessary social services for a resident with a PASRR Level II, who had a history of cerebrovascular accident, dementia, depression, and bipolar disorder. Despite being cognitively intact, the resident did not receive an annual psychiatric evaluation as recommended. Additionally, the resident expressed dissatisfaction and a desire to move, but there was no documentation or follow-up on this issue. The social worker did not document conversations with residents and referred behaviors to nursing staff, contrary to care plan requirements.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in actual harm to two residents with severe cognitive impairment. In one incident, a resident with dementia and a BIMS score indicating severe cognitive impairment was grabbed by another resident while attempting to take their food tray, resulting in visible bruising and redness on the arm. This was observed by a CNA and confirmed by an RN who assessed the injuries. The facility's investigation and interviews confirmed the occurrence of the incident. In a separate incident, another resident with severe cognitive impairment, non-traumatic brain dysfunction, and dependent on staff for transfers, was found yelling for another resident to leave their room. A CNA responded and found the aggressive resident leaning over the affected resident, who had a red mark on their cheek and reported being slapped. The incident was confirmed through staff interviews and facility investigation. Both incidents demonstrate a failure to ensure residents' right to be free from physical abuse as outlined in the facility's abuse prevention policy.
Failure to Provide Scheduled Showers and Maintain Hygiene for Dependent Resident
Penalty
Summary
A resident with diagnoses including hypertension, diabetes mellitus, and arthritis, who was cognitively intact and wheelchair bound, required partial to moderate assistance with bathing and had a care plan indicating the need for help with activities of daily living (ADLs) due to weakness and pain. Despite being scheduled for showers three times weekly and having requested this frequency at admission, the resident reported going several days without a shower, a fact corroborated by their representative. The facility's bathing records showed gaps where the resident was neither provided nor offered a shower for periods of 9 and 10 consecutive days. Interviews with the Director of Nursing (DON) confirmed that there was no documentation of showers being offered or provided during these periods, and that staff were expected to document both bathing and any refusals. Facility policies required that residents unable to perform ADLs receive necessary services to maintain grooming and hygiene, and that showers be provided per request or schedule. The lack of documentation and failure to provide or offer showers as scheduled led to the deficiency in maintaining the resident's personal hygiene.
Failure to Honor Residents' Right to Manage Personal Funds
Penalty
Summary
The facility failed to honor the residents' right to manage their personal funds, as evidenced by the review of trust fund account statements for two residents. For the first resident, multiple instances were identified where payments from the Social Security Administration (SSA) were deposited into the resident's account, but subsequent payments to the facility left the resident with no balance or a negative balance, without evidence of the resident receiving their $50 personal needs allowance. This pattern was observed over several months, indicating a consistent failure to allocate the personal needs allowance to the resident. Similarly, for the second resident, SSA payments were deposited into the resident's account, but payments to the facility left the resident with insufficient funds to cover the $50 personal needs allowance. Additionally, after the resident was discharged, the facility continued to receive SSA payments, which were used to pay the facility, leaving the resident with a zero balance. An interview with the former administrator revealed that the residents' personal funds allowances were being used to pay down large debts owed to the facility, contrary to the residents' rights and Medicaid requirements.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with memory problems and diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and dementia, who was sitting at a table in the dining area when another resident approached and struck them on the face. Staff were unaware of the altercation until the resident called out, as they had their backs turned at the time. The resident was assessed with no immediate injury, but a bruise was noted the following day. Surveillance footage confirmed that the attack was unprovoked. The resident who committed the abuse had a history of verbal and physical aggression towards both staff and other residents, as documented in their progress notes. Despite this history, the resident was left unsupervised, which allowed the altercation to occur. The facility's incident report noted that the aggressor was calm and engaged in a puzzle before and after the incident, indicating a lack of immediate provocation or warning signs. The facility's policy on abuse, neglect, and exploitation emphasizes the need for trained and qualified staff to identify and intervene in situations where abuse is likely to occur. However, the incident revealed gaps in staff supervision and awareness, as well as a failure to adequately address the behavioral issues of the aggressive resident. The performance improvement plan identified several root causes, including insufficient staff education on behavioral health, lack of documentation, and poor communication between nursing staff and physicians.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to develop and implement policies and procedures for ensuring the timely reporting of suspected abuse, neglect, or theft, specifically regarding the reasonable suspicion of a crime. This deficiency was identified in two of five sample residents reviewed for allegations of abuse. The facility's policy, implemented on 5/30/23, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes. However, a resident-to-resident altercation on 12/9/24 was reported to facility administration promptly but was not reported to the state survey agency until 12/12/24, exceeding the required timeframe. Similarly, another altercation on 12/25/24 was reported to administration promptly but was not reported to the agency until later that day. Interviews with the former administrator, the current administrator, and the social service director confirmed that the allegations were not reported within the required timeframe.
Deficiencies in Behavioral Health Care for Residents with Dementia
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to residents with dementia, resulting in actual harm to one resident. Resident #97, who had non-traumatic brain dysfunction and non-Alzheimer's dementia, exhibited aggressive and combative behaviors over several months. Despite a physician's verbal order for a psychological evaluation, there was no evidence that the evaluation was completed. The resident's care plan lacked effective interventions for managing aggressive behaviors, and the facility did not document attempts to schedule the evaluation or the neurologist's progress notes. The resident's behavior escalated to the point where staff had to barricade themselves and other patients for safety, leading to the resident's removal from the facility by emergency services. Another resident, #4, who had cerebrovascular accident, non-Alzheimer's dementia, depression, and bipolar disorder, expressed suicidal ideations through notes and verbal statements. Despite these indications, there was no follow-up documentation or evidence of effective interventions. The resident's care plan included redirection and monitoring, but the facility lacked a current policy on suicidal behaviors. The mental health agency had stopped seeing the resident, and the facility was waiting for guidance on how to proceed, leaving the resident without adequate support. Interviews with facility staff revealed gaps in documentation and communication regarding the residents' behavioral health needs. The NHA confirmed the lack of documentation for scheduling attempts and progress notes, while the social worker admitted to not documenting conversations with residents. The facility's failure to address these deficiencies in behavioral health care and services contributed to the residents' unmet needs and potential harm.
Deficiency in 24-Hour Nursing Coverage Documentation
Penalty
Summary
The facility failed to maintain a system to document licensed nurses on duty 24 hours a day, as required. A review of the PBJ Staffing Data Report revealed that on multiple occasions in July, October, November, and December, the facility did not provide continuous nursing coverage. Specifically, on certain days, the Director of Nursing (DON) was scheduled for 12-hour shifts, but there was no documentation to confirm coverage for the remaining hours. The Nursing Home Administrator (NHA) acknowledged the issue, noting that the previous PBJ data entry person was no longer employed, and the current system did not allow the salaried DON to clock in without payroll complications. This lack of documentation led to the deficiency in ensuring 24-hour nursing coverage.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary manager met the required qualifications. During an interview, the dietary manager disclosed that she had not completed the Certified Dietary Manager coursework, although she planned to complete it soon. The facility census was 43, and it was noted that a dietician was present on-site every Tuesday for 8 hours.
Failure to Implement Water Management Program and Review IPCP
Penalty
Summary
The facility failed to implement a comprehensive water management program as part of its Infection Prevention and Control Program (IPCP) to prevent, detect, and control the risk of water-borne pathogens. The IPCP policy, which was implemented on May 22, 2023, lacked evidence of an annual review and necessary updates. Additionally, the facility did not perform primary prevention strategies for Legionella, despite having a policy in place since May 2021. These strategies were supposed to include diagnostic testing, investigation for a facility source of Legionella, and physical and temperature controls. An interview with the former Nursing Home Administrator (NHA) confirmed that the IPCP policy had not been reviewed in the past year, and there was no documentation to show that the water management program had been implemented.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged to a short-term general hospital. The medical record review and staff interview revealed that the discharge summary, which should have included a recapitulation of the resident's stay, was not completed. The resident was admitted to the facility and discharged without an anticipated return. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Conduct Regular Bed Rail Safety Evaluations
Penalty
Summary
The facility failed to ensure regular safety evaluations of bed rails for a resident. During an observation, it was noted that a resident had assist bars at the head of the bed, but the last safety evaluation for these assist bars was conducted over three years ago. The facility's policy requires that safety assessments be conducted annually, but an interview with the MDS coordinator confirmed that no further documentation of such assessments was available. This oversight indicates a lapse in adhering to the facility's policy on the regular evaluation of assistive devices for safety.
Deficiency in Dementia Care for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with dementia, resulting in a deficiency in care. The resident, who had severe cognitive impairment due to alcohol-induced persisting dementia, was involved in multiple resident-to-resident altercations over several months. Despite these incidents, the resident's care plan lacked specific interventions to address these behaviors. The care plans for cognitive loss/dementia and behavioral symptoms included general interventions but did not effectively address the resident's aggressive behaviors. Additionally, the facility did not develop a behavioral care plan or conduct a professional evaluation of the resident's behaviors. The facility's documentation and communication regarding the resident's care were inadequate. Progress notes indicated that the resident was somnolent due to strong medications, yet no assessment or behavioral care plan was developed. A scheduled counseling appointment was canceled due to the resident's combative behavior and lack of clarity about the appointment details. During an interdisciplinary care plan conference, the resident's behaviors were not discussed, and the social worker involved in the resident's care did not document encounters in the resident's record. The former nursing home administrator confirmed that there was no system in place to ensure a professional evaluation of the resident's behaviors, and the medical director had not been consulted.
Failure to Provide Medically Related Social Services for Resident with PASRR Level II
Penalty
Summary
The facility failed to provide medically related social services for a resident with a PASRR Level II, as identified through a review of medical records, staff interviews, and policy reviews. The resident, who was readmitted from the hospital, had a history of cerebrovascular accident, non-Alzheimer's dementia, depression, and bipolar disorder, and was cognitively intact with a BIMS score of 15 out of 15. The resident's care plan included interventions for suicidal ideations, such as redirection and offering to contact a counselor or family. However, the PASRR Level II recommendations for rehabilitative services, including supportive counseling and an annual comprehensive psychiatric evaluation, were not followed, as there was no evidence of an annual psychiatric evaluation in the resident's medical record. Additionally, a progress note indicated that the resident expressed dissatisfaction with the facility and a desire to move, which was reported to the social services director and the DON, but there was no documentation or follow-up on this conversation. An interview with the social worker revealed that she did not document conversations with residents and would refer any resident behaviors to the nursing staff. The social worker also indicated that care plan interventions should be documented in the progress notes, which was not done in this case.
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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