Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thermopolis Rehabilitation And Wellness during CMS and state inspections, most recent first.
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 resident with a BIMS of 15, heart failure, morbid obesity, anxiety disorder, and PTSD was dependent on staff for transfers and used a mechanical lift. During an observed transfer from wheelchair to bed, CNAs and an RN used an Invacare Reliant 450 lift while locking the rear casters during the lift and lowering process. RNs and the DON confirmed the practice, and the manufacturer’s instructions stated the rear casters should not be locked during lifting procedures.
A resident with HF, AFib, HTN, a pacemaker, and hypo-osmolality/hyponatremia received midodrine for hypotension despite a BP reading above the ordered parameter. The MAR showed the noon dose was given when BP was 122/41, even though the order said the med may be stopped if BP was above 110. The MA-C said she would normally hold the med and notify a supervisor or charge nurse if BP was outside parameters, but the record showed no evidence the physician was contacted about the elevated BP before the dose was given.
Unbagged Soiled Linen Transported in Hallway: An RN was observed carrying unbagged soiled linen down the East hall and taking it to the soiled laundry bin. The IP coordinator and NHA stated soiled linen should be bagged before removal from rooms and transport, and CDC guidance plus facility policy required bagging soiled laundry prior to transport.
A resident with diabetes and dementia had all diabetes medications and glucose monitoring discontinued after a hospital stay, but the primary physician was not notified. When the resident later showed signs of hyperglycemia and had critically high blood glucose readings, there was a delay in contacting the physician, and staff did not follow facility policy to call for urgent changes. The physician confirmed she was not informed of these significant changes or the elevated glucose levels.
A resident with diabetes and dementia did not receive appropriate blood glucose monitoring or timely physician notification after diabetes medications were discontinued post-hospitalization. Despite exhibiting symptoms of hyperglycemia and having critically high blood glucose readings, nursing staff did not follow protocols for immediate physician contact or intervention, and a continuous glucose monitor was never implemented as ordered.
The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to obtain them, resulting in noncompliance with regulatory requirements.
A resident was not offered pneumococcal immunizations according to CDC guidelines. Despite having received two doses of PPSV23 in the past, there was no evidence of an offer for further vaccination since admission. The facility's policy and CDC recommendations suggest a dose of PCV-20 for adults of a certain age, but this was not adhered to, resulting in a deficiency.
A facility failed to respond to an abuse allegation involving a CNA who verbally abused and attempted to physically move a resident against their will. Despite the incident being reported and witnessed by staff, the abusive CNA continued to work multiple shifts, and the grievance was not logged or investigated promptly, leading to immediate jeopardy.
A facility failed to protect a resident from verbal abuse by a CNA, who yelled at the resident and attempted to forcibly remove them from a chair. The incident was witnessed by another CNA and an LPN, but the grievance was not properly logged or addressed by the facility, leading to a deficiency in protecting the resident's rights.
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.
Mechanical Lift Casters Locked During Resident Transfer
Penalty
Summary
The facility failed to ensure appropriate use of a mechanical lift during one observed transfer for a resident who was cognitively intact with a BIMS score of 15 out of 15 and had diagnoses including heart failure, morbid obesity, anxiety disorder, and post-traumatic stress disorder. The resident was dependent on staff for chair/bed-to-chair transfers and had a care plan noting ADL function decline related to reduced mobility from morbid obesity, weakness, and chronic health conditions, with use of a mechanical lift for transfers. During observation, two unidentified CNAs and RN #1 assisted the resident from a wheelchair to bed using an Invacare Reliant 450 full body mechanical lift. A full body sling was placed under the resident, the lift was positioned over the resident, and the sling was attached to the lift. One CNA locked the caster brakes while the resident was raised out of the wheelchair, unlocked the caster brakes as the resident was positioned over the bed, and then locked the caster brakes again before lowering the resident into bed. RN #1, RN #2, and the DON confirmed that the rear casters were locked during the transfer, and the manufacturer’s instructions stated that Invacare does not recommend locking the rear casters during lifting procedures because it could cause the lift to tip.
Significant medication error with midodrine administration
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error involving midodrine, which was ordered for hypotension. The resident’s admission MDS showed a BIMS of 15/15 and diagnoses including heart failure, atrial fibrillation, hypertension, a cardiac pacemaker, and hypo-osmolality/hyponatremia. The physician order dated 11/14/25 directed midodrine 5 mg by mouth three times daily with meals for hypotension, with an additional instruction that the medication may be stopped if blood pressure was above 110. On 11/16/25, the resident’s blood pressure was documented as 122/41 at 1:06 PM before the scheduled noon dose, yet the midodrine was still administered by MA-C #1. The same day, the resident also had blood pressures of 107/56 at 8:07 AM and 101/41 at 4:42 PM, with no other blood pressures documented. MA-C #1 stated she would hold midodrine if blood pressure was higher than the ordered parameters and notify a supervisor or charge nurse, and later stated she contacted the physician on 11/16/25 to obtain parameter orders because there were none at the time of administration. However, the medical record contained no evidence that the physician was contacted that day regarding the 122/41 reading. A progress note provided during the survey stated that blood pressure was taken before giving the medication and was low, but after the meal the blood pressure was above the parameter to give.
Unbagged Soiled Linen Transported in Hallway
Penalty
Summary
The facility failed to ensure effective infection prevention practices were followed during linen transportation. During an observation on 11/17/2025 at 2:25 PM, RN #3 was seen walking down the East hall carrying unbagged soiled linen in her hands and transporting it to the soiled laundry bin. During an interview on 11/20/25 at 11:35 AM, the infection prevention coordinator and NHA stated that soiled linen should be bagged before being removed from rooms and transported to the soiled laundry bin. Review of CDC standards of practice titled Laundry and Bedding, last revised 1/08/24, showed soiled laundry should be bagged prior to transporting to the soiled linen room. Review of the facility policy titled Infection Control Policies and Practices, last revised 5/30/23, also reflected the facility's infection control policies and practices for preventing transmission of infections and communicable diseases.
Failure to Notify Physician of Resident's Change in Condition and Elevated Blood Glucose
Penalty
Summary
The facility failed to ensure timely physician notification of a change in condition for a resident with diabetes and non-Alzheimer's dementia. After returning from the hospital, all of the resident's diabetes medications and blood glucose monitoring were discontinued per new orders, but there was no evidence that the primary physician was notified of these changes. Subsequently, the resident exhibited symptoms of hyperglycemia, including polyuria, polydipsia, and polyphagia, with blood glucose readings as high as 567. Despite these critical findings, there was a delay in notifying the physician, and interventions were not promptly implemented. Staff interviews revealed that the nurse relied on faxing the physician rather than calling, even though the facility had emergency insulin available and the policy expected a call for urgent changes in condition. Further interviews with facility leadership and the resident's physician confirmed that the physician was not notified of the discontinuation of diabetes management or the elevated blood glucose levels. The physician stated she would have expected to be called if the blood glucose exceeded 400, and that there was always an on-call physician available. The facility's policy recommended provider notification for blood sugars less than 70 or greater than 350, but this was not followed in the resident's case.
Failure to Provide Timely Diabetes Management and Physician Notification
Penalty
Summary
A deficiency was identified in the facility's management of a resident with diabetes mellitus and non-Alzheimer's dementia. Upon admission, the resident was to have a continuous glucose monitor (CGM) to avoid frequent fingerstick blood sugar checks, but there was no evidence that a CGM was ever implemented. The resident's diabetes medications and blood glucose monitoring were discontinued following a hospital visit, with no documentation that the primary physician was notified of these changes. After returning from the hospital, the resident exhibited symptoms of hyperglycemia, including polyuria, polydipsia, and polyphagia, and had extremely elevated blood glucose readings (over 500 mg/dL), but there was no immediate intervention or timely physician notification as required by facility policy and physician expectations. Nursing staff failed to follow established protocols for notifying the physician when the resident's blood glucose exceeded the recommended parameters. Instead of calling, staff relied on fax communication, which delayed the response. Interviews with facility leadership confirmed that the expectation was for nurses to call the physician in cases of significant changes in condition or abnormal blood glucose levels, but this did not occur. Additionally, the facility had insulin available in the emergency kit, but the nurse did not administer it or contact the physician directly, citing a lack of available insulin, which was contradicted by the emergency kit inventory. The resident's physician was not informed of the discontinuation of diabetes medications and monitoring, nor of the subsequent hyperglycemic episodes. The physician stated she would have expected to be notified of blood glucose levels greater than 400 mg/dL and clarified that there was always an on-call physician available. The facility's policy also specified provider notification for blood sugar levels less than 70 or greater than 350 mg/dL, but these protocols were not followed. The lack of timely notification and intervention resulted in the resident not receiving appropriate treatment and monitoring for their diabetes.
Failure to Ensure Timely, Approved X-Ray Services
Penalty
Summary
The facility failed to provide timely, approved x-ray services or to have an agreement with an approved provider to obtain such services. This deficiency was identified based on the facility's inability to ensure that x-ray services were available as required, either directly or through a formal agreement with an approved provider. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Offer Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that a resident was offered pneumococcal immunizations in accordance with CDC recommendations. The medical record review revealed that the resident, who was admitted at an advanced age, had received two doses of the PPSV23 vaccine in 2003 and 2008. However, there was no evidence that the resident was offered a pneumococcal vaccine since their admission. During an interview, the Director of Nursing (DON) and the Deputy Director of Clinical Operations (DDCO) confirmed the lack of documentation showing that the resident was offered a pneumococcal vaccine post-admission. The facility's policy, updated in March 2022, recommends that adults of a certain age receive a dose of PCV-20, even if they have previously received one or more doses of the vaccine before turning 65. The CDC's Adult Immunization Schedule also indicates that individuals who have only received PPSV23 should receive a dose of PCV15 or PCV20 at least one year after the last PPSV23 dose. Despite these guidelines, the facility did not offer the recommended pneumococcal immunization to the resident, leading to the identified deficiency.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to respond to an allegation of abuse and protect a resident's right to be free from verbal abuse by a staff member. The incident involved a CNA who verbally abused a resident and attempted to physically move the resident against their will. The grievance was reported by another CNA and witnessed by an LPN, but the facility did not take immediate action to investigate or protect the resident. The abusive CNA continued to work multiple shifts following the incident, and the grievance was not logged in the facility's grievance log. Interviews with staff revealed that the incident was reported to the Business Office Manager (BOM), who asked the reporting CNA to document it in writing. Despite this, the grievance was not acted upon promptly, and the abusive CNA remained on duty. The facility's failure to investigate the abuse allegation and protect the resident led to a determination of immediate jeopardy. The facility's policy required immediate reporting and investigation of abuse allegations, which was not followed in this case.
Removal Plan
- CNA #2 was suspended pending an investigation.
- An abuse allegation investigation was started which included resident interviews and reporting of the allegation to the appropriate entities.
- Education was provided to all staff on abuse reporting notification and investigation which included education of oncoming staff before contact with residents.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. The incident involved a resident who was frequently incontinent of urine and occasionally incontinent of bowel. On the day of the incident, a CNA verbally abused the resident by telling them they smelled wrong and attempting to forcibly remove them from a chair. The resident protested, and the CNA yelled at the resident, causing noticeable distress. Another CNA intervened and reported the incident to the business office manager, but the grievance was not logged in the facility's grievance log for February 2024. Witness statements from another CNA and an LPN corroborated the incident, describing the yelling and the resident's distress. The LPN heard the yelling from the nurse's station and observed the resident visibly upset when she arrived at the scene. The CNA who intervened also provided a detailed account of the incident, including the resident's elevated and high-pitched voice when upset. The facility's Director of Nursing (DON) and regional nurse consultant were unaware of the grievance form's whereabouts and acknowledged the incident was not acceptable. The facility's policy on the prevention of abuse, neglect, and exploitation was reviewed, showing that the grievance process should be utilized for concerns expressed by staff members. The policy also emphasized the importance of supervising staff to identify inappropriate behaviors and strictly prohibited retaliation against staff for reporting concerns. Despite these policies, the facility failed to document and address the grievance properly, leading to a deficiency in protecting the resident from verbal abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Thermopolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Worland Health And Rehabilitation | 29.4 mi | ★★★★★ | 6 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.