The Legacy Living And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gillette, Wyoming.
- Location
- 1000 S Douglas Way, Gillette, Wyoming 82716
- CMS Provider Number
- 535022
- Inspections on file
- 31
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 48
Citation history
Health deficiencies cited at The Legacy Living And Rehabilitation Center during CMS and state inspections, most recent first.
Two cognitively intact residents experienced repeated mental abuse and sexual harassment from another resident, including exposure and inappropriate propositions, with staff present during at least one incident but failing to intervene. The facility did not revise care plans or implement required assessments for the resident exhibiting aggressive behavior, contrary to policy.
Multiple residents with severe cognitive impairment and behavioral challenges were involved in physical altercations, resulting in injuries such as a hematoma, abrasion, skin tear, and bruising. The incidents occurred when one resident followed others into a suite and was pushed, and when another resident entered a room uninvited, leading to a struggle. Insufficient supervision and ineffective implementation of care plan interventions contributed to the failure to prevent these incidents.
Several residents with severe cognitive impairment and behavioral challenges were involved in unwitnessed altercations, resulting in minor injuries, after one resident entered another's room and another was pushed to the floor. Both incidents occurred during a period of increased activity and insufficient supervision, despite care plans identifying risks and the need for staff intervention.
A facility failed to report an allegation of drug toxicity or overdose for a resident who was found unresponsive and later pronounced deceased. Despite being aware of the allegation, the facility did not report it to the state survey agency, as they believed a previous report was sufficient, although it did not include the specific allegation.
A resident with severe cognitive impairment and a history of wandering exited a facility unnoticed and was found deceased outside after over nine hours in winter conditions. Despite door alarms sounding, staff failed to check outside, violating protocols for monitoring high-risk residents.
A resident with Alzheimer's disease and severe cognitive impairment exited a facility unnoticed and was found deceased after being outside in freezing temperatures for over nine hours. The facility failed to provide adequate supervision and did not respond properly to door alarms, leading to the resident's unsupervised exit and death.
A resident with multiple health conditions expressed concerns about having pneumonia and a heart attack, requesting to be sent to the hospital. Despite these complaints and unusual symptoms, the nursing staff did not notify the physician or take appropriate action, leading to the resident's death. The nurse responsible was terminated for failing to respond to the resident's needs.
A resident with severe cognitive impairment was neglected and abused by CNAs in an LTC facility. Surveillance showed a CNA neglecting the resident for 13 hours, while another CNA was caught on video verbally and physically abusing the resident. The resident expressed fear about calling for help after these incidents.
The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. One resident experienced sexual abuse on two occasions, another resident was physically abused resulting in bruising and skin tears, and a third resident was pushed, resulting in a fall and head injury. The facility's documentation and follow-up on these incidents were inadequate.
A facility failed to provide appropriate treatment and services for a resident with dementia, resulting in multiple incidents of aggressive behavior, wandering, and incontinence. Despite severe cognitive impairment and documented behavioral issues, the facility did not develop a comprehensive care plan or analyze behavior triggers, leading to actual harm.
The facility failed to monitor temperatures for six refrigerator/freezers storing food for resident use, with internal temperatures often exceeding the recommended 40 degrees Fahrenheit. Additionally, a cook did not perform proper hand hygiene after handling raw hamburger patties, and had not completed the required Serve Safe certification. These actions were not in compliance with the facility's policy and the 2022 FDA Food Code.
The facility failed to ensure mail was delivered to residents on Saturdays. Seven residents reported that the transportation aide, who was previously responsible for Saturday mail delivery, informed them that this service would no longer occur. The DON confirmed the transportation aide's responsibility for weekend mail delivery, and the aide confirmed that mail had not been delivered on Saturdays for about four months.
The facility failed to ensure a safe and homelike environment in the Pine unit, as residents from the Cottonwood unit frequently wandered into the Pine unit, causing disturbances and safety concerns. Staff and family members reported increased behavioral issues, missing items, and resident altercations. Despite grievances, the facility did not adequately address the concerns, leaving Pine residents and their families worried about safety.
The facility failed to provide food service at safe and appetizing temperatures, with issues such as incorrect serving scoops, insufficient food, and delays in meal service. Residents complained of cold, dry, burnt food, and warm drinks. The dietitian confirmed the need for education to dietary aides to improve efficiency.
The facility failed to ensure advance directives were properly formulated for two residents, leading to discrepancies between physician orders and the residents' Cardiopulmonary Resuscitation Directives. Staff interviews revealed inconsistencies in how advance directives were determined.
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment and Alzheimer's disease. The incident, where another resident had their hand down the resident's pants, was not followed up on or reported to the state licensing division as required by facility policy.
The facility failed to investigate an allegation of abuse involving a resident with severe cognitive impairment and diagnoses including Alzheimer's disease and depression. Despite documentation of the incident, the facility did not follow up, and the DON and ADON were initially unable to identify the involved resident. It was later confirmed that the allegation had not been investigated or reported to the state licensing division as required.
The facility failed to ensure a discharge notice included care and services for a resident which should not or cannot be provided by the facility. The family was involved in inappropriate wound care, refused pain management, and made medical decisions without informing the facility. The facility issued a 30-day discharge notice, and the family felt it was in retaliation for filing a grievance. The DON confirmed the facility could meet the resident's care needs, but the family's requests were against the resident's wishes.
The facility failed to ensure accurate MDS assessment information for a resident, incorrectly coding them as taking an antibiotic despite no evidence of a prescription in their medical records. The MDS coordinator confirmed the error.
The facility failed to ensure a PASARR level II was performed for a resident who had a PASARR level I indicating the need for a level II. The resident had diagnoses including PTSD and major depressive disorder, and the DON confirmed the PASARR level II was not requested at the time of admission.
The facility failed to develop comprehensive person-centered care plans for three residents with severe cognitive impairments. One resident's care plan did not specify hypersexual behaviors, another's did not address the use of an antianxiety medication, and a third's lacked an analysis of triggers for physical aggression.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed antibiotics on four occasions due to delays in medication delivery and failure to utilize available alternatives in the pyxis emergency inventory.
The facility failed to ensure a safe environment for two residents with severe cognitive impairments, leading to multiple incidents including altercations, ingestion of harmful substances, and inadequate supervision. Despite being identified as requiring constant supervision, the residents were observed wandering and engaging in unsafe behaviors. The facility did not develop effective interventions to ensure their safety.
The facility failed to ensure proper handling of urinary Foley catheter bags to prevent urinary tract infections for a resident with neurogenic bladder and a history of urinary tract infection. A CNA was observed lifting the catheter bag above the resident's waist, causing urine to flow back toward the bladder, contrary to facility policy.
The facility failed to follow enhanced barrier precautions for a resident with an indwelling catheter and a urinary tract infection. Staff did not wear gowns and gloves as required, improperly managed the urinary catheter, and did not post the necessary signage indicating the precautions.
Failure to Protect Residents from Mental Abuse by Peer
Penalty
Summary
The facility failed to protect residents from mental abuse by another resident, as evidenced by multiple incidents involving inappropriate sexual behavior and harassment. One cognitively intact resident with a history of non-traumatic brain dysfunction, cerebral palsy, anxiety disorder, depression, and bipolar disorder reported that another resident exposed their genitalia and made inappropriate requests in a common area. The affected resident expressed feeling unsafe and fearful due to repeated unwanted advances, including gestures that were perceived as threatening, though no physical contact occurred. Another cognitively intact resident with medically complex conditions reported a similar incident where the same resident entered their room, grasped their own genitals through their pants, and made sexually suggestive comments. This resident also reported previous inappropriate propositions from the same individual in the dining room and noted that other residents had experienced similar behavior but were unwilling to speak up. Staff were reportedly nearby during at least one incident but did not intervene at the time. The facility's policy required assessment and care plan revision in response to resident aggression, but these measures were not implemented for the resident involved in the incidents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse during a series of resident-to-resident altercations. One incident involved a resident with severe cognitive impairment and a history of wandering and entering others' personal space, who was pushed to the ground by another resident after following them into their suite. This resulted in the resident sustaining a hematoma above the left eyebrow and an abrasion under the left eye. The care plan for this resident had identified the risk of harm from others due to cognitive deficits, but interventions to prevent such incidents were not effectively implemented at the time of the altercation. Another incident involved a resident with severe cognitive impairment and anxiety who experienced distress when another resident entered their room without permission. The two residents were found on the floor kicking at each other after one entered the other's room, resulting in minor injuries including a skin tear, bruise, and scratch. The care plan for the resident who was protective of personal space included interventions to redirect other residents, but these measures were not sufficient to prevent the altercation. Staff interviews and documentation revealed that the facility was undergoing a transition that increased resident agitation and led to a rise in resident-to-resident incidents. The root cause was identified as insufficient supervision throughout the unit, which contributed to the failure to prevent these altercations. The lack of timely staff intervention allowed the incidents to escalate, resulting in actual harm to at least one resident.
Failure to Prevent Resident-to-Resident Altercations Due to Insufficient Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for four residents involved in two unwitnessed resident-to-resident altercations. In one incident, a resident with severe cognitive impairment, non-traumatic brain dysfunction, Alzheimer's disease, and a history of wandering entered another resident's room. The second resident, also with severe cognitive impairment, Alzheimer's disease, Parkinson's disease, and anxiety, became agitated, resulting in both residents being found on the floor kicking at each other. Both sustained minor injuries, including a skin tear and bruising. The incident was unwitnessed, and the resident who was entered upon had a care plan indicating significant anxiety about others entering their room, preferring the door open but being highly protective of personal items. In another event, a resident with severe cognitive impairment and a history of being close to others was found on the floor near another resident's room. The second resident, also with severe cognitive impairment, hallucinations, delusions, and a history of verbal and physical behaviors, admitted to pushing the first resident, stating the other had been annoying. The incident was not witnessed by staff, and the resident who was pushed did not sustain injuries. Both residents had care plans identifying risks related to proximity to others and potential for physical aggression, with interventions to redirect and separate them as needed. The facility was undergoing a transition from two secure units to one, which increased resident activity and contributed to a rise in resident-to-resident incidents. Staff interviews and documentation revealed that insufficient supervision throughout the unit was identified as a root cause of these incidents. The lack of adequate staff presence and monitoring allowed for unwitnessed altercations to occur, despite existing care plans outlining the need for supervision and redirection for residents with behavioral challenges and cognitive impairments.
Failure to Report Allegation of Drug Toxicity
Penalty
Summary
The facility failed to report an allegation of drug toxicity or overdose for a resident, which was a reasonable suspicion of a crime. The resident, who was cognitively intact and had multiple diagnoses including heart failure, hypertension, and diabetes mellitus, was found unresponsive and later pronounced deceased. A newspaper article indicated that the police were investigating the death as a potential overdose of a prescription medication. Despite being aware of this allegation, the facility did not report it to the state survey agency. Interviews with the resident's physician and nurse practitioner confirmed their awareness of the drug toxicity allegation. The Director of Nursing and the administrator acknowledged that the facility had initiated an investigation but did not report the specific allegation of drug toxicity or overdose, as they believed a previous report surrounding the resident's death was sufficient. However, the previous report did not include the specific allegation of drug toxicity or overdose.
Neglect Leads to Resident's Death Due to Elopement
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident's death. The resident, who had severe cognitive impairment and a history of exit-seeking behavior, exited the facility unnoticed and was outside in winter conditions for over nine hours. The resident was dependent on staff for various activities of daily living and had a care plan indicating the need for close supervision due to wandering behaviors. On the night of the incident, staff on the Cottonwood unit were unable to locate the resident at approximately 4 AM. A search was initiated, and the resident was found outside without signs of life. Closed-circuit camera footage revealed that the resident exited the facility at 7:08 PM the previous evening and fell to the ground shortly after. The resident remained outside in the snow until being discovered by staff the following morning. The facility's protocol required staff to visually check the area outside when an alarm sounded, but this was not done. Interviews with staff indicated that door alarms went off during the night, but staff did not check outside due to concerns about being locked out or because other residents were near the doors. The facility's policy required interventions to mitigate wandering risks, including door alarms and staff rounding, but these measures were not effectively implemented. The failure to provide necessary services to prevent harm led to the determination of immediate jeopardy.
Failure to Supervise Resident Leads to Fatal Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident with severe cognitive impairment and a history of wandering. The resident, who had Alzheimer's disease and required substantial assistance with daily activities, was able to exit the facility unnoticed. The resident's care plan indicated a need for close supervision due to exit-seeking behavior, but this was not effectively implemented. On the night of the incident, the resident exited the facility into the courtyard and was outside in freezing temperatures for over nine hours. Closed-circuit camera footage showed the resident leaving the building and falling to the ground, where they remained until discovered deceased the following morning. Staff interviews revealed that door alarms were not properly responded to, and the resident was not accounted for during routine checks. The facility's policy required staff to visually check outside when alarms sounded, but this was not done. Staff on duty failed to follow protocols for monitoring high-risk residents and responding to door alarms, contributing to the resident's unsupervised exit and subsequent death. The deficiency was identified as an immediate jeopardy situation due to the lack of intervention and supervision.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to respond appropriately to a change in condition for a resident who was cognitively intact and had multiple diagnoses, including heart failure and diabetes. The resident expressed concerns about having pneumonia and requested to be sent to the hospital. Despite these complaints, the resident's vital signs were noted as within normal limits, and no distress was observed. The resident was given a breathing treatment and was later found unresponsive, leading to their death. Interviews with staff revealed that the resident had expressed concerns about having a heart attack and not feeling well, which were reported to the nursing staff. However, the nurse responsible did not notify the resident's physician or take further action beyond administering a breathing treatment. The resident continued to exhibit unusual symptoms, such as needing assistance with transfers and experiencing seizure-like shaking, which were not typical for them. The facility's Director of Nursing and Assistant Director of Nursing confirmed that the nurse did not follow protocol by failing to notify the physician of the resident's change in condition and request for hospitalization. The nurse was subsequently terminated for not responding to the resident's needs, which ultimately resulted in the resident's death.
Resident Abuse and Neglect by CNAs
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as well as neglect, as evidenced by incidents involving two CNAs. The resident, who had severe cognitive impairment and was dependent on staff for personal care, was left unattended in the bathroom and went unchecked for 13 hours during a CNA's shift. This neglect was captured on audio/video surveillance, and other staff reported concerns about the conditions of residents, such as saturated briefs and beds, and dried feces and urine left on beds. In another incident, the resident's daughter provided video footage showing a CNA verbally and physically abusing the resident. The footage showed the CNA pushing the resident in bed, pulling the resident up by one arm, and using aggressive and threatening body language. The CNA was also observed turning off the resident's call light and refusing to take the resident to the bathroom, leading to the resident expressing fear about calling for help. Interviews revealed that the CNA involved in the physical and verbal abuse had complained about being overwhelmed and needing help. The CNA stated that she had no intention of hurting the resident and was frustrated during the shift. The resident's daughter reported these incidents to the facility, and the resident exhibited new fearful behavior following the incidents.
Removal Plan
- Resident assessment
- CNA suspension
- Facility reported to adult protection agency, state survey agency, and state board of nursing
- Disciplinary action for the perpetrators
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. Resident #106, who has severe cognitive impairment due to Alzheimer's disease, experienced sexual abuse on two occasions. On one occasion, another resident was found with their hand up Resident #106's shirt, and on another occasion, the same resident had their hand down Resident #106's pants. The facility did not follow up on these incidents adequately, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unable to identify the resident involved in one of the incidents during an interview. Resident #63, who also has severe cognitive impairment, was physically abused by another resident, resulting in bruising and skin tears. The aggressor resident grabbed Resident #63's left forearm and attempted to twist it, causing injuries. The facility's documentation of the extent of the injuries and post-event monitoring was incomplete, as confirmed by the ADON and DON. Resident #26 was involved in an altercation with another resident, resulting in a fall and head injury. The aggressor resident pushed Resident #26, causing them to fall and hit their head on the floor. Both residents were transported to the emergency department, and Resident #26 did not require stitches. The facility implemented one-to-one staff supervision for the aggressor resident following the incident. The facility's policy emphasizes the importance of providing a safe environment and protecting residents from abuse, but these incidents indicate a failure to adhere to these standards.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to ensure that a resident with dementia received appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, traumatic brain injury, and depression, exhibited multiple behavioral issues such as wandering, physical aggression, and incontinence. Despite these behaviors, the facility did not develop or implement a comprehensive, resident-centered care plan to address these issues effectively. The care plans lacked specific non-medication interventions for pain management, and there was no evidence of an analysis of triggers for the resident's aggressive behaviors or appropriate interventions for their neurological deficits. The resident's behavior included wandering into other residents' rooms, urinating and defecating on the floor, and being physically aggressive towards staff. Multiple incidents were documented where the resident was combative during care, such as hitting and kicking staff during incontinence care and showering. The resident also engaged in disruptive behaviors like drinking hand sanitizer, eating other residents' food, and intruding into other residents' rooms, which caused distress among other residents. Despite these documented behaviors, the facility did not update the resident's care plan to include specific interventions to manage these behaviors. Interviews with staff, including LPNs and CNAs, revealed that the resident was difficult to care for due to their aggressive behaviors and wandering tendencies. Staff reported that the resident often refused care and was not easily redirected. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that a thorough analysis of the resident's behavior triggers and professional evaluations had not been completed. This lack of comprehensive assessment and intervention led to the resident's continued behavioral issues and actual harm, as evidenced by multiple documented incidents of aggression and self-harm.
Temperature Monitoring and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure proper temperature monitoring for six refrigerator/freezers storing food for resident use outside of the kitchen. Observations revealed discrepancies between external and internal thermometer readings, with internal temperatures often exceeding the recommended 40 degrees Fahrenheit. Additionally, one refrigerator lacked an internal thermometer altogether. Interviews with the dietitian confirmed that monitoring of these refrigerators and freezers was not being conducted. The facility's policy required daily documentation of refrigerator/freezer temperatures, which was not being followed, leading to potential food safety issues for the residents. In the food preparation area, a cook was observed handling raw hamburger patties with gloved hands and then, without performing hand hygiene, donning new gloves to handle seasoning containers. This practice was confirmed by the dietitian as incorrect, and the cook had not completed the required Serve Safe certification by the designated deadline. The facility's policy and the 2022 FDA Food Code mandate proper hand hygiene and temperature monitoring to ensure food safety, both of which were not adhered to in this instance.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure mail was delivered to residents on Saturdays. During a group interview, seven residents reported that the transportation aide, who was previously responsible for Saturday mail delivery, informed them that this service would no longer occur. The Director of Nursing (DON) confirmed that the transportation aide was responsible for weekend mail delivery. The transportation aide further confirmed that the post office delivered mail after he left the facility at 11 AM, resulting in no Saturday mail delivery for about four months.
Failure to Ensure Safe and Homelike Environment in Pine Unit
Penalty
Summary
The facility failed to ensure a safe and homelike environment in the Pine unit, as residents from the Cottonwood unit frequently wandered into the Pine unit, causing disturbances and safety concerns. Multiple observations and interviews revealed that Pine staff had to redirect Cottonwood residents who intruded into Pine residents' rooms, leading to missing items and resident altercations. Medical records showed that one particular resident from Cottonwood exhibited aggressive behaviors, intruding into rooms, taking belongings, and causing distress among Pine residents and their families. Interviews with staff and resident representatives highlighted the negative impact of opening the doors between the Cottonwood and Pine units. Staff reported increased behavioral issues and safety concerns, with Pine residents feeling fearful and unsafe. The facility's decision to open the doors was based on an initial risk evaluation that deemed the dementia levels similar between the units, but no reevaluation was conducted. Staffing levels were not adjusted to accommodate the increased supervision needs, leading to further strain on Pine unit staff. Family members of Pine residents expressed frustration and concern over the lack of privacy and safety, with some documenting multiple instances of uninvited intrusions and missing personal items. Despite grievances and complaints, the facility's management did not address the concerns adequately, leaving the Pine unit residents and their families dissatisfied and worried about their safety and well-being.
Deficiency in Food Service Temperature and Quality
Penalty
Summary
The facility failed to provide food service in a manner that ensured a safe and appetizing meal for residents in the Pine, Cottonwood, and Birch units. During an observation, the steam table food cart was transported from the kitchen to the Pine unit, and the temperature of the turkey casserole was recorded at 180 degrees Fahrenheit. However, several issues were identified: the dietary aide did not have the correct serving scoops, had to redirect a wandering resident, and did not have enough food for all diet types, causing delays. The nutrition supervisor had to assist, and the meal service, which should have been completed within 20 minutes, extended to 40 minutes. On the Cottonwood unit, the meal service started late, and the turkey noodle casserole was served at 128 degrees Fahrenheit, which was lukewarm when tasted by the surveyor. Residents complained of food being served cold, dry, burnt, and with inconsistent portion sizes, as well as warm drinks with no ice. The dietitian confirmed the need for education to dietary aides to increase speed and efficiency in serving meals, with an expectation for food to be held at 140 degrees Fahrenheit. The facility's Food Preparation Practices policy requires hot food to be served immediately after preparation and held at a temperature of 135 degrees Fahrenheit and above. The 2022 FDA Food Code also mandates that time/temperature control for safety food should be maintained at 135 degrees Fahrenheit or above. The facility's failure to adhere to these guidelines resulted in food being served at unsafe and unappetizing temperatures, leading to resident complaints and observations of deficiencies in the food service process.
Failure to Ensure Proper Formulation of Advance Directives
Penalty
Summary
The facility failed to ensure advance directives were properly formulated for two residents. For resident #14, there was a discrepancy between the physician's order, which indicated a do not resuscitate (DNR) status, and the resident's Cardiopulmonary Resuscitation Directive, which requested full code status. For resident #21, the physician's order indicated a DNR status, but the advance directive was unselected in the resident's medical record. Interviews with staff revealed inconsistencies in how advance directives were determined, with some staff consulting the resident's profile and others looking at an advance directive binder or a blue dot on the resident's door nameplate, which indicated full code status.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were reported for one resident reviewed for abuse. Resident #62, who had severe cognitive impairment and diagnoses including Alzheimer's disease and depression, was involved in an incident where another resident had their hand down Resident #62's pants. The facility did not follow up on the incident and was initially unable to identify the involved resident. Upon identification, it was confirmed that the allegation of abuse had not been reported to the state licensing division. A review of the state licensing division incident database showed no evidence that the incident had been reported, despite the facility's policy requiring immediate reporting of such allegations.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were investigated for one resident reviewed for abuse. Resident #62, who had severe cognitive impairment with a BIMS score of 5 out of 15 and diagnoses including Alzheimer's disease and depression, was involved in an incident where another resident had their hand down Resident #62's pants. Despite this incident being documented in a progress note, the facility did not follow up on the incident, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unable to identify the involved resident at the time of the interview. It was later confirmed that the resident involved was Resident #62, and the allegation of abuse had not been investigated or reported to the state licensing division as required by the facility's abuse policy.
Failure to Provide Adequate Discharge Notice and Care Coordination
Penalty
Summary
The facility failed to ensure a discharge notice included care and services for a resident which should not or cannot be provided by the facility. The interdisciplinary team met with the family to discuss care decisions that violated the resident's wishes as outlined in the Medical Durable Power of Attorney (MDPOA). The family was involved in inappropriate wound care and refused to make decisions to treat the resident's pain, which was ongoing due to their perceptions of pain medicine. The family also made medical orders and provided prescription-level wound care supplies without the knowledge of the wound care team and facility providers. Additionally, the family reported an allergy to digoxin and a UTI to outside providers without informing the facility, despite the resident receiving appropriate care for these conditions. The family scheduled appointments without notifying the facility, making transportation arrangements unfeasible. The family was inconsistent in care decisions, impacting the resident's care, and pursued clinical efforts outside the physician's patient management, leading to the facility's decision to issue a 30-day discharge notice. A progress note showed that the DON contacted the family member to follow up on the resident's status and discussed the care transition, explaining that the facility could not meet the resident's needs and issued a 30-day discharge notice. The family member was informed about the appeal process and the contact information for the State ombudsman and licensing agency. The family member initially requested a camera in the resident's room but later declined, stating it would be a waste of money if the resident was being discharged. Referrals for long-term care were sent to other nursing facilities and skilled nursing facilities. An interview with a family member revealed that they felt the discharge notice was issued in retaliation for filing a grievance related to neglect. The DON confirmed that the facility could meet the resident's care needs, but the family's requests for care were against the resident's wishes. The care and services provided at the referred nursing facilities and skilled nursing facilities were the same level of care and services the facility was able to provide.
Inaccurate MDS Assessment for Antibiotic Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment information accurately reflected the resident's status for one resident reviewed for antibiotics. Specifically, the annual MDS assessment for the resident indicated that they were taking an antibiotic, with the indication noted box also checked. However, a review of the resident's physician orders and the medication administration records for January and February 2024 showed no evidence that the resident had been prescribed an antibiotic. An interview with the MDS coordinator confirmed that the resident had not been prescribed an antibiotic and that the MDS assessment was coded incorrectly. This discrepancy was identified based on staff interviews, medical record reviews, and a review of the Resident Assessment Instrument (RAI) manual.
Failure to Complete PASARR Level II for Resident
Penalty
Summary
The facility failed to ensure a pre-admission screen and resident review (PASARR or PASRR) was performed for a resident who had a PASARR level II indicated. The medical record review showed that the resident was admitted to the facility and the PASARR level I completed at the time of admission indicated the need for a PASARR level II. However, there was no evidence that a PASARR level II was completed at that time. An Authorization Request Summary later showed a review type as PASRR Level 2, indicating the resident had diagnoses including post-traumatic stress disorder and major depressive disorder, with mental health rehabilitation services potentially recommended. The Director of Nursing (DON) confirmed in an interview that the PASARR level II was not requested when the PASARR I was completed and was unsure why it was not requested until a later date. The facility's policy stated that all residents are required to have a PASARR Level I screen completed prior to nursing facility admission and that PASARR Level I and II (when applicable) will be kept on file in the resident's medical record and kept accurate according to OBRA and state regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for three residents with severe cognitive impairments. Resident #62, who had Alzheimer's disease and depression, was receiving an antidepressant for depression and hypersexuality. However, the care plan did not specify the hypersexual behaviors exhibited by the resident, despite the facility's awareness of the resident's preference for residents of the opposite gender. This was confirmed during an interview with the DON and ADON. Resident #63, also with severe cognitive impairment and diagnosed with Alzheimer's disease, unspecified dementia, and anxiety, was prescribed buspirone for anxiety. The care plan, however, only addressed the use of an antidepressant for depression and did not include a plan for the antianxiety medication. The ADON mistakenly believed buspirone was an antidepressant. Resident #98, who had a traumatic brain injury and severe cognitive impairment, had a care plan that included analyzing triggers for physical aggression but lacked evidence that this analysis was completed. The DON and ADON confirmed that the analysis had not been done.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician. The resident, who had severe cognitive impairment and multiple diagnoses including cancer, anemia, malnutrition, Alzheimer's disease, and recurrent UTIs, was prescribed 500 mg of ampicillin to be administered four times a day. However, the facility did not administer the medication four times between the order date and the next administered dose. The delay was attributed to the unavailability of the medication from the primary and backup pharmacies, and the nursing staff did not explore the option of substituting amoxicillin, which was available in the pyxis emergency inventory. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the process for obtaining medications involved ordering from the primary pharmacy, with a potential delay if the order was placed after 2 PM. The staff could use the pyxis for immediate needs, but this option was not utilized in this case. The facility's medication administration policy required new medication orders to be started on the same day, but this was not adhered to, resulting in missed doses for the resident.
Failure to Ensure Safe Environment for Residents with Severe Cognitive Impairments
Penalty
Summary
The facility failed to ensure a safe environment for two residents with severe cognitive impairments, leading to multiple incidents. Resident #26, diagnosed with Alzheimer's disease and having a BIMS score indicating severe cognitive impairment, was observed wandering between units and picking up items and food. The resident was involved in an unwitnessed altercation with another resident, resulting in a fall and head injury. Additionally, the resident was found with zinc oxide paste in their mouth, which was stored in resident rooms for incontinence care. These incidents indicate a lack of adequate supervision and intervention to prevent harm to the resident. Resident #98, also with severe cognitive impairment and diagnosed with Alzheimer's disease, traumatic brain injury, and depression, was involved in several incidents due to inadequate supervision. The resident was involved in an unwitnessed altercation with another resident, resulting in a scratched earlobe. The resident was also found drinking hand sanitizer and consuming various items from the kitchen. Despite being identified as requiring constant supervision, the resident was observed wandering into staff areas and other residents' rooms, taking belongings and becoming agitated when redirected. The facility's failure to develop and implement effective interventions to ensure the safety of these residents was confirmed in an interview with the DON and ADON.
Improper Handling of Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure proper handling of urinary Foley catheter bags to prevent urinary tract infections for a resident with neurogenic bladder and a history of urinary tract infection. During an observation, a CNA was seen lifting the urinary catheter bag above the resident's waist while untangling the tubing, causing cloudy urine to flow back toward the resident's bladder. Additionally, the CNA held the urinary bag above the bladder when transferring the resident to a wheelchair. The CNA later confirmed that she had been educated to keep the urinary catheter bag below the bladder. The ADON and infection preventionist also stated that it was the facility's expectation for staff to maintain the catheter bag below the bladder. Review of the facility's policy on urinary catheter care confirmed that the drainage bag must be positioned lower than the bladder at all times to prevent backflow of urine.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for a resident with an indwelling catheter and a urinary tract infection. The resident's care plan required staff to use gowns and gloves for high-contact activities, but observations showed that two CNAs only wore gloves while dressing the resident and handling the urinary catheter. Additionally, the CNAs improperly managed the urinary catheter, causing cloudy urine to flow back towards the resident's bladder. No signage indicating the required EBP was posted on the resident's door or wall. Interviews with the ADON and infection preventionist confirmed that the facility's policy required gowns and gloves for care involving catheters and wounds. The EBP sign was found tucked inside the PPE storage unit on the resident's door, and staff had been trained on EBP in the previous months. The facility's policy on EBP, dated 1/6/23, specified the use of gowns and gloves for high-contact activities and required signage to be posted outside the resident's room indicating the type of precaution and PPE required.
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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