Wind River Rehabilitation And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverton, Wyoming.
- Location
- 1002 Forest Dr, Riverton, Wyoming 82501
- CMS Provider Number
- 535031
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Wind River Rehabilitation And Wellness during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including osteoporosis and morbid obesity, had physician orders for weekly alendronate and tirzepatide that were repeatedly not administered because the medications were documented as "on order from pharmacy" over several months. MAR review showed numerous missed doses of alendronate and a gap in tirzepatide orders and administration, while a physician note indicated the resident ran out of tirzepatide and that staff had not picked up alendronate from the pharmacy or called for refills. The physician reported ongoing problems with medications not being available, lack of notification from the facility, and failure by staff to pick up ordered medications despite being informed of pharmacy pickup timeframes and alternative local pharmacy options.
A resident with chronic sacral and lower extremity wounds and a newly placed Foley catheter received perineal, catheter, and sacral wound care from the DON and an LPN without the use of required enhanced barrier precautions. During the observed care, staff performed hand hygiene and used gloves, changing them between care steps, but did not don gowns or any additional PPE. The DON later acknowledged that residents with wounds and indwelling devices should be on enhanced barrier precautions, and facility policy specified that gowns and gloves are required for high-contact care of residents with chronic wounds or indwelling medical devices.
Staff in the kitchen used hand sanitizer instead of washing hands with soap and water between food preparation tasks, including after handling raw meat and before preparing salads. The dietary manager was unaware that this practice was not compliant, and the facility's policy stated that antimicrobial gels cannot replace proper handwashing in foodservice. The FDA Food Code requires handwashing with soap and water before using hand antiseptics.
Multiple infection prevention and control lapses were identified, including a resident's Foley catheter bag left uncovered on the floor, improper storage of oxygen tubing for two residents, an LPN administering medications without changing gloves or hand hygiene, and a staff member transporting unbagged soiled linen without gloves. Additionally, a resident with pneumonia and a UTI was exposed to staff moving between ill residents without proper infection control practices.
Surveyors found persistent strong urine odors in a care unit, including hallways, a dining area, and a resident's room, despite staff assistance and administrative awareness of the issue. The facility did not ensure a clean, odor-free environment for residents.
Two residents did not receive activities tailored to their preferences and needs, with one bedbound resident unable to participate due to lack of a wheelchair and staff assistance, and another resident with anxiety and depression reporting no interest in available activities and minimal participation documented. The activities director confirmed gaps in one-to-one activity provision and a lack of nighttime options, despite facility policy requiring individualized activities.
An LPN administered medications to a resident by opening a duloxetine delayed release capsule and crushing a potassium chloride extended release tablet, both of which should have been swallowed whole according to manufacturer guidelines and facility policy. This resulted in a medication error rate of 7.69%, exceeding the acceptable 5% threshold.
A resident with paraplegia and morbid obesity, who was cognitively intact and dependent on staff for mobility, was not assisted out of bed or provided with a suitable wheelchair as requested. The resident expressed a desire to get up and bathe in the whirlpool, but staff were unaware of these preferences and no wheelchair was available, resulting in the resident remaining bedbound since admission.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility without staff knowledge on two occasions, despite being identified as a high elopement risk. The resident was found outside the facility by staff and law enforcement after each incident. The facility did not provide adequate supervision or ensure the environment was free from accident hazards, resulting in a deficiency.
A resident with severe cognitive impairment physically abused another resident, resulting in bruising and a scrape. The facility updated the care plan and placed the perpetrator on 1:1 supervision. However, the facility did not provide documentation of post-incident steps, such as staff education or monitoring, with the last abuse education occurring before the incident.
The facility failed to monitor two residents with edema according to physician orders. One resident with heart failure and other conditions did not have daily weights documented on multiple dates, as confirmed by the administrator and physician. Another resident, concerned about swollen legs, had an order for daily weights for five days, but only one weight was documented. The administrator and physician confirmed the weights were not performed as ordered.
The facility failed to follow physician's orders and professional standards for two residents with pressure ulcers. One resident's condition worsened due to inadequate repositioning and missing documentation of wound care. Another resident experienced a delay in wound vac placement, with verbal orders not entered into the electronic health record. The facility lacked a wound care policy, leading to deficiencies in care.
A facility failed to implement physician-ordered medication changes for a resident with multiple diagnoses, including CAD and diabetes. Despite receiving the medications from the pharmacy, they were not entered into the system, and the resident did not receive them. The DON attributed the oversight to a transition period, and the administrator noted a nurse's misunderstanding of the medications as refills.
The facility failed to promptly identify and intervene for acute changes in condition for two residents. One resident experienced severe shoulder pain after a fall and did not receive timely medical evaluation or pain management. Another resident exhibited signs of increased back pain after a fall and was not sent for x-rays until several days later, revealing compression fractures. Both residents experienced actual harm due to the facility's inaction.
A resident with chronic pain conditions experienced severe pain following a fall, but the facility failed to administer the ordered PRN Oxycodone and did not document the pain level and location. The resident's pain was inadequately managed with only topical gel and routine Tylenol, leading to actual harm and a delayed medical evaluation.
The facility failed to ensure a safe and clean environment, with issues such as broken floor tiles, unsanitizable handrails, a dirty mechanical lift, and damaged heater vent covers. Persistent urine smells and built-up dirt and debris were also noted. Interviews revealed awareness of these issues and ongoing efforts to address them.
The facility was found deficient in food safety practices, including improper use of hair restraints by the CDM, inadequate hand hygiene and glove use by kitchen staff, and failure to manage expired food items. The CDM did not wear a beard restraint, and a cook used the same gloves for different tasks without washing hands, violating the 2022 Food Code. Expired tortillas were also found in storage, with the CDM unaware of their status.
The facility failed to follow the menu for residents on a consistent carbohydrate diet (CCHO) during a lunch meal. Multiple residents were served cranberry sauce over pork, whole or half potatoes, beets, and rolls, contrary to the specified CCHO menu. The certified dietary manager confirmed the discrepancies.
A facility failed to follow proper infection prevention techniques during wound care for a resident. An RN did not change gloves or perform hand hygiene between handling soiled and clean dressings, and used contaminated scissors without cleaning them. The infection preventionist confirmed these actions did not meet expected standards.
Two residents with pressure ulcers did not receive necessary wound care as per physician orders in a timely manner. One resident, at risk due to renal insufficiency, developed a blister on the heel, and another with cellulitis had a stage 2 ulcer. Both residents lacked documented care on specific days, and the DON could not provide additional documentation, indicating a deficiency in wound care management.
The facility failed to provide therapeutic diets as ordered, with two residents receiving improperly thickened liquids. A CNA used an unlabeled thickener for a resident with a specific order, resulting in coughing, while another CNA used thickener for a resident without an order. Staff interviews revealed confusion over thickener use, with the DON stating that dietary staff should handle thickening.
A resident with severely impaired cognition had their hair cut by facility staff without family consent, despite prior arrangements for a specific hairdresser. The family filed a grievance, expressing dissatisfaction with the unauthorized haircut, which was intended to make the resident presentable for Thanksgiving.
The facility failed to follow its grievance procedure for a resident who reported missing items upon discharge. The resident's representative reported the missing items to the social services director, but a grievance form was not completed, and the grievance was not logged. The facility's grievance policy requires that grievances be routed to the appropriate personnel and logged, with a written decision provided to the person with the grievance.
Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for a cognitively intact resident with paraplegia, cervicalgia, spina bifida, morbid obesity, and osteoporosis. The resident had physician orders for weekly oral alendronate sodium for osteoporosis and weekly subcutaneous tirzepatide (Zepbound) for morbid obesity. Review of the MARs over several months showed alendronate was repeatedly not administered and documented as “on order from pharmacy” on multiple scheduled administration dates in August, September, October, November, December, and January. In addition, there was a gap in tirzepatide orders and administration, with no evidence of an active order or administration for a period in December despite a prior start date and a later increased-dose order. A physician consult documented that the resident had run out of tirzepatide and that no one had called for a refill, and also that the SNF had not picked up the alendronate, despite the physician’s review with nursing and the DON that these medications needed to be picked up and not allowed to run out. The physician further reported ongoing issues with medications not being available, the facility not notifying him, and the facility not picking up medications from the pharmacy, even though he had informed them that medications would be available for pickup within 24–48 hours after ordering and that they could obtain them from a local pharmacy if needed. These actions and inactions by facility staff led to multiple missed doses of ordered medications for the resident.
Failure to Use Enhanced Barrier Precautions During Wound and Catheter Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not using enhanced barrier precautions during wound care for one resident. The resident had an open sacral wound documented by telephone order on 1/11/26 and an open wound on the right lower extremity documented in a progress note on 1/18/26. A hospital discharge summary dated 1/23/26 further showed the resident had been treated for a right lower extremity wound and cellulitis, had an open sacral wound, and had a newly placed Foley catheter. These conditions met the facility’s criteria for enhanced barrier precautions, including the presence of chronic wounds and an indwelling medical device. During an observation of wound care on 2/5/26 at 9:22 AM, the DON and an LPN entered the resident’s room, performed hand hygiene, and donned gloves. The DON provided perineal and Foley catheter care due to incontinence of loose stool, then changed gloves and performed sacral wound care, including removal of the dressing, cleansing of the wound, and application of a new dressing, with hand hygiene and glove changes between steps. However, no gown or other additional personal protective equipment was used at any time during the care. In a subsequent interview, the DON stated that enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities, should be used for residents with wounds, catheters, and similar devices, and confirmed that this resident should have been on enhanced barrier precautions. Review of the facility’s Transmission-Based Precautions policy, last updated March 2025, showed that enhanced barrier precautions are required for residents with chronic wounds or indwelling medical devices.
Improper Hand Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen as required by professional standards and the 2022 FDA Food Code. During observation, a cook was seen using hand sanitizer instead of washing hands with soap and water between food preparation tasks, including after handling raw meat and before preparing salads. The cook sanitized her hands with gel sanitizer and donned gloves between tasks, only washing her hands with soap and water after several steps. Interviews with the cook and the dietary manager confirmed that staff routinely used hand sanitizer between glove changes, and the dietary manager was unaware that this practice was not compliant with food safety standards. Review of the facility's own handwashing policy indicated that antimicrobial gels cannot be used in place of proper handwashing in a foodservice setting. The FDA Food Code specifies that hand antiseptics may only be used on hands that have already been properly washed, and if not meeting certain criteria, must be followed by thorough rinsing with clean water before food contact or glove use.
Infection Control Lapses in Catheter, Respiratory, Medication, and Linen Handling
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several areas, as observed through staff interviews, medical record reviews, and policy reviews. For one resident with a Foley catheter, the catheter bag was found on the floor and uncovered while the resident was in bed, contrary to facility policy requiring the bag to be secured below the bladder and covered. Another resident diagnosed with pneumonia and later a UTI was reportedly exposed to staff moving between ill residents without appropriate infection control measures, as described by the resident's representative and confirmed by the DON that there were multiple cases of respiratory illness in the facility during that period. Additional deficiencies were observed in respiratory care, where two residents' oxygen tubing and nasal cannulas were improperly stored, left balled up or touching equipment instead of being placed in designated storage bags as per policy. During medication administration, an LPN handled medications with gloved hands that had touched other surfaces, without changing gloves or performing hand hygiene, before administering the medications. Furthermore, a staff member was seen transporting unbagged soiled linen in her ungloved hand across the hall, which was inconsistent with facility policy requiring soiled linen to be bagged and handled with gloves when removed from resident rooms.
Failure to Maintain Odor-Free and Clean Environment
Penalty
Summary
Surveyors observed persistent strong urine odors in one of four resident care units over several days. On multiple occasions, strong urine odors were noted in the hallway near the assisted dining room, near specific resident rooms, and within the assisted dining area itself. In one instance, a resident's room continued to have a strong urine odor even after the resident had left and staff had provided assistance. During an interview, the facility administrator acknowledged awareness of the ongoing odor issue and stated that while some improvement had occurred, further action was still needed. The facility had also been discussing alternative storage for soiled linen on the affected hall. These findings indicate that the facility failed to maintain a clean, odor-free environment as required, impacting the comfort and homelike atmosphere for residents.
Failure to Provide Individualized Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide individualized activities based on resident preferences for two of three sampled residents. One resident, who was cognitively intact and bedbound due to paraplegia, spina bifida, and morbid obesity, expressed a strong desire for reading materials, music, and outdoor access, but was unable to participate in activities due to the lack of a wheelchair and insufficient staff to assist with mobility. Documentation showed this resident did not participate in any group activities over a 73-day period and only received one-to-one activities on five occasions, with all other activities marked as independent. The resident reported feeling isolated and noted a lack of staff engagement in their room. Another cognitively intact resident with anxiety and depression also reported that none of the facility's activities were of interest. This resident's records indicated participation in only one group activity and two one-to-one activities over a 94-day period, with the remainder marked as independent. The activities director confirmed the lack of documented one-to-one activities and acknowledged that there were no activities available at night, which was when this resident was most active. Facility policy required the provision of individualized and in-room activities, but these were not consistently provided according to the residents' needs and preferences.
Medication Error Rate Exceeds Threshold Due to Improper Administration
Penalty
Summary
During a medication administration observation, an LPN prepared and administered seven medications to a resident, including potassium chloride extended release and duloxetine hydrochloride delayed release. The LPN opened the duloxetine capsule and placed its contents in a medication cup, then crushed the potassium chloride tablet along with other medications before mixing them with applesauce and administering them to the resident. Review of the resident's physician orders indicated that medications could be crushed unless contraindicated, but specifically ordered duloxetine as a delayed release capsule and potassium chloride as an extended release tablet, both of which should not be altered. Manufacturer guidelines for both duloxetine delayed release and potassium chloride extended release specify that these medications should be swallowed whole and not crushed, chewed, or opened. The facility's own policy also states that long-acting, extended release, or enteric coated dosage forms should generally not be crushed, and alternatives should be sought. The medication error rate during this observation was calculated at 7.69%, exceeding the acceptable threshold of 5%.
Failure to Accommodate Resident's Mobility and Bathing Preferences
Penalty
Summary
A deficiency was identified when a resident with paraplegia, spina bifida, and morbid obesity, who was cognitively intact and dependent on staff for mobility, was not accommodated according to their expressed needs and preferences. The resident reported being bedbound since admission and expressed a desire to get out of bed and use a wheelchair, as well as to bathe in the whirlpool. Observation confirmed the absence of a wheelchair in or near the resident's room, and the resident had not been assisted out of bed since admission. Interviews with facility staff revealed a lack of communication regarding the resident's preferences. The social services director was unaware of the resident's desire to get up or their bathing preferences. The administrator and DON indicated that therapy was attempting to contact the resident's family to obtain the resident's personal wheelchair, as the facility's available shower chair was unsuitable due to the resident's poor trunk control. The regional clinical director confirmed that therapy was assessing the safety of using a facility wheelchair and that the resident was to discuss the matter with their family. Despite these discussions, the resident remained bedbound and their needs and preferences were not accommodated.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15 and a diagnosis of moderate dementia with behavioral disturbances, was admitted to the facility. The initial elopement risk evaluation did not identify the resident as an elopement risk, but subsequent assessments and care plan updates noted a history of attempts to leave the facility unattended, impaired safety awareness, and verbalized intent to go home. Despite these risk factors, the resident was able to leave the facility without staff knowledge on two separate occasions. On one occasion, the resident was noticed missing after having spent most of the day outside. Staff initiated a search, contacted local law enforcement, and found the resident returning to the facility after having walked to a store. On another occasion, the resident was again found missing, and staff discovered the resident's wanderguard device on the floor of the resident's room. After a search and notification of police, the resident was located walking on a main street and brought back to the facility. The resident refused a full body skin assessment upon return. Observations during the survey confirmed that the resident continued to spend time outside, often accompanied by 1:1 staff supervision. Interviews with the resident and the resident's representative confirmed the resident's preference for being outdoors and the facility's ongoing efforts to monitor and supervise the resident. The facility's failure to prevent the resident from leaving the premises without staff knowledge, despite known risk factors and previous incidents, constituted a deficiency in providing adequate supervision and ensuring the environment was free from accident hazards.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. The incident involved a resident with severe cognitive impairment who exhibited physical behavioral symptoms. This resident, while ambulating to their room, encountered another resident and pinched them on the arm. The care plan for the perpetrating resident was updated to reflect the altercation, and they were placed on a 1:1 supervision following the incident. The victim, also with severe cognitive impairment, sustained bruising and a slight scrape on the arm, with documentation noting scratch marks with dried blood. The facility's investigation revealed that the incident was witnessed by staff, and the perpetrating resident was placed on 1:1 supervision immediately. However, the facility failed to provide documentation of steps taken after the incident, such as staff education, audits, monitoring, or quality assurance measures. The last recorded staff education on abuse was conducted prior to the incident, and no further documentation was provided to show any additional measures taken to prevent future occurrences.
Failure to Monitor Residents with Edema as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring in accordance with physician's orders for two residents with edema. Resident #16, who had diagnoses including heart failure, renal insufficiency, pulmonary hypertension, and localized edema, was ordered daily weights starting on 10/29/24. However, the medical record showed that daily weights were not documented on several dates, and the administrator confirmed that the weights were not done as per the physician's orders. Physician #1 also confirmed that the daily weights were not conducted as ordered. Similarly, Resident #14, who expressed concern about swollen legs, had an order for daily weights for five days starting on 11/4/24, with instructions to notify the physician if there was a 3-pound gain in 24 hours. The treatment administration record and vital signs log revealed only one weight documented on 11/5/24. The administrator confirmed the order for daily weights was either not done or not documented, and physician #1 confirmed the daily weights were not performed as ordered.
Deficient Wound Care Documentation and Practice
Penalty
Summary
The facility failed to provide care in accordance with physician's orders and professional standards of practice for two residents with pressure ulcers. One resident, who was bedbound due to myelopathy and had chronic recurring pressure ulcers, experienced a worsening of their condition from a stage 3 to a stage 4 pressure ulcer on the sacrum. Despite being on an air mattress and having good nutrition and diabetes control, the resident frequently refused repositioning, which was necessary for pressure relief. The facility's documentation was lacking, with multiple instances where wound care was not documented as completed according to physician orders. Additionally, the facility did not have a wound care policy, and the administrator acknowledged missing documentation for wound care on several occasions. Another resident, admitted with cellulitis of the groin and a multi-drug resistant organism, was supposed to have a wound vac placed upon admission, but it was delayed by a day. The wound care nurse performed a dressing change with verbal orders from the provider but failed to enter them into the electronic health record. There were no documented orders for wound care until the wound vac was received, and the facility's policy required immediate input of physician's orders into the electronic health record. The physician confirmed that an order for wound care was given prior to the wound vac's arrival due to the wound's condition.
Failure to Implement Physician-Ordered Medication Changes
Penalty
Summary
The facility failed to provide medications to meet the needs of a resident diagnosed with abscess liver, coronary artery disease (CAD), hypertension, and diabetes mellitus. On 9/26/24, a physician documented medication changes for the resident, including starting aspirin for CAD, Ursodiol for a pericholecystic abscess, stopping Furosemide to monitor volume status, and switching diabetes medication from Glipizide to Empagliflozin. However, a review of the medication administration record (MAR) revealed that these changes were never implemented before the resident's discharge. The Director of Nursing (DON) acknowledged the oversight, attributing it to a transition period as she was new to the role. The facility received the medications from the pharmacy, but they were not entered into the system, and the resident did not receive them. The administrator explained that the nurse who signed for the medications mistakenly thought they were refills, not new prescriptions.
Failure to Promptly Identify and Intervene for Acute Changes in Condition
Penalty
Summary
The facility failed to promptly identify and intervene for an acute change in condition for two residents who experienced a change in condition. Resident #29, who had diagnoses including polyosteoarthritis and non-Alzheimer's dementia, fell and complained of severe shoulder pain. Despite multiple observations and complaints of pain, the resident did not receive a thorough assessment or timely medical intervention. The resident's pain was not adequately managed, and there was a delay in scheduling an appointment with the primary care physician, leading to the resident being sent to the ER for imaging two days after the fall, where old injuries aggravated by the fall were identified. Resident #31, who had severe cognitive impairment and non-Alzheimer's dementia, fell and exhibited signs of increased back pain. Despite multiple nursing notes indicating the resident's pain and guarding behavior, the resident was not sent for x-rays until several days after the fall. The x-rays revealed age-indeterminate compression fractures and degenerative arthroplasty. The delay in sending the resident for imaging was attributed to a lack of communication among the nursing staff and the DON. Both residents experienced actual harm due to the facility's failure to promptly assess and intervene for their acute changes in condition. The lack of timely medical evaluation and pain management resulted in prolonged discomfort and delayed diagnosis of injuries for both residents.
Inadequate Pain Management Following Resident Fall
Penalty
Summary
The facility failed to adequately treat pain for a resident who experienced a change in condition, including limited movement and severe pain following a fall. The resident, who had diagnoses including polyosteoarthritis, non-Alzheimer's dementia, and other chronic pain, was found on the floor with a new laceration and shoulder pain. Despite the resident's complaints of severe pain, rated as high as 10, the staff did not administer the PRN Oxycodone as ordered and instead only applied topical Diclofenac Sodium Gel and gave routine Tylenol. The resident's pain level and location were not documented on the MAR for the day of the fall, and the resident was not seen by a doctor until the following day when imaging was ordered due to increased pain and decreased function of the arm. The resident was later found to have aggravated old injuries but no acute injury and was sent back to the facility with a sling and pain medication from the hospital ER. The facility's policy required pain levels to be evaluated every shift and treated accordingly, but this was not followed in the resident's case, leading to inadequate pain management and actual harm to the resident.
Facility Fails to Ensure Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe and clean environment for residents, staff, and the public. Observations revealed multiple issues, including broken floor tiles with built-up dirt and debris, discolored and unsanitizable handrails, and a mechanical lift with dirt and debris on the standing platform. Additionally, a heater vent cover in a resident's room had visible rust and sharp edges, and the carpet in a common area was worn down and discolored. The tan and black couch in the same area had visible discoloration and tears in the cushions. A persistent urine smell was noted in the hallway near certain rooms, and transitions between hallways and rooms had built-up dirt and debris. These observations were confirmed by the maintenance director and housekeeping manager, who acknowledged the cleanliness and safety concerns, including damaged heater vent covers and chipped handrails with sharp edges. Interviews with the administrator, maintenance director, and housekeeping supervisor revealed awareness of the cleanliness issues and ongoing efforts to address them. The administrator mentioned plans to end the contract with the current housekeeping agency and upgrade certain areas, including the carpet in the television area. The maintenance director and housekeeping supervisor confirmed the difficulty in cleaning certain areas due to alarmed doors and plumbing leaks. They also acknowledged the time-consuming process of sanding and sealing handrails and the safety risks posed by damaged heater vent covers and handrails.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and preparation, as evidenced by several observations. The certified dietary manager (CDM) was observed on multiple occasions not wearing a beard restraint while in the kitchen and during tray line service, despite the 2022 Food Code requiring such restraints to prevent hair from contacting food and clean equipment. The CDM admitted to being aware of beard restraints but had never worn one. Additionally, during tray line service, a cook was observed using the same pair of gloves to touch both microwave buttons and food items, such as grilled cheese sandwiches and baked potatoes, without changing gloves or performing hand hygiene in between tasks. This was contrary to the 2022 Food Code, which mandates handwashing and glove changes between different tasks to prevent cross-contamination. The facility also failed to manage expired food items properly. During an inspection of the dry storage room, two packages of flour tortillas were found to be expired. Despite this, one of the expired packages remained on the shelf during a subsequent observation. The CDM was unaware of the expired status of these tortillas and initially claimed that all items in dry storage were usable. Upon further inspection, it was revealed that the entire box of flour tortillas received by the facility was expired, indicating a lapse in monitoring and managing food inventory effectively.
Failure to Follow CCHO Diet Menu
Penalty
Summary
The facility failed to ensure the menu was followed for residents on a consistent carbohydrate diet (CCHO) during the lunch meal on 3/13/24. The menu for the CCHO diet specified baked pork loin without cranberry sauce, half a baked potato, beets, and no roll. However, observations during tray line service revealed that multiple residents on the CCHO diet were served cranberry sauce over the pork, whole or half potatoes, beets, and rolls. Specifically, residents with different texture modifications such as puree and soft and bite-sized textures also received cranberry sauce and rolls, contrary to the menu requirements. The certified dietary manager confirmed that the CCHO diet should not have included cranberry sauce or rolls and should have included only half a potato.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention techniques during wound care for a resident. During an observation, an RN was seen cleaning a surgical wound on the resident's abdomen without removing her gloves or performing hand hygiene before handling clean dressings. The RN also used scissors from her pocket to cut tape and applied it to the dressing without cleaning the scissors. Additionally, the RN touched the floor with clean gloves while changing the resident's heel dressing, then proceeded to handle clean dressings and scissors without changing gloves or performing hand hygiene. The contaminated scissors were then placed back into the RN's pocket without being cleaned. An interview with the wound nurse/infection preventionist confirmed that the RN's actions did not meet the expected infection control standards. The infection preventionist stated that items used in a resident's room should be considered contaminated and cleaned before leaving the room. She also confirmed that gloves should be changed after cleaning a wound and before touching clean dressings to prevent contamination. A review of professional guidelines supported these expectations, emphasizing the importance of hand hygiene and proper glove use during wound care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment to promote healing for two residents with pressure ulcers. Resident #50, who was at risk for pressure ulcers due to renal insufficiency, developed a serosanguinous filled blister on the left heel shortly after admission. Despite physician orders for daily dressing changes, the resident reported not receiving treatment for a couple of days, and the medical record lacked documentation of wound care on two specific days. The Director of Nursing (DON) confirmed that wound documentation should be in the medical record but did not provide additional evidence of care. Similarly, resident #105, diagnosed with weakness and cellulitis, had a stage 2 pressure ulcer on the right heel. Physician orders required daily dressing changes, but the medical record showed no evidence of treatment on the same two days as the other resident. The DON again stated that wound documentation should be present but failed to provide further documentation. These lapses in care and documentation indicate a deficiency in the facility's wound care management.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure therapeutic diets were provided in accordance with physician's orders during meal observations. Specifically, thickened liquids were not appropriately provided for two residents. During an observation, a CNA used an unlabeled and undated container of white powder, referred to as thickener, to prepare a drink for a resident with an active physician's order for mildly thick liquid consistency. The resident coughed several times after drinking and did not consume more of the beverage. Another CNA was observed using a similar unlabeled container of thickener for a different resident, who did not have an active order for thickened liquids. The CNA admitted to being unfamiliar with the powdered thickener and typically used a liquid thickener with a pump for consistency. Interviews with staff revealed that the kitchen usually measured out the powdered thickener, and the facility typically used liquid thickener with instructions for use. However, the containers on the cart lacked scoops for measurement. The facility dietitian indicated that questions about thickening liquids should be directed to the DON and administrator, and that pre-thickened liquids were available. The DON stated that floor staff should not be responsible for thickening liquids, as this task should be performed by dietary staff only.
Failure to Respect Resident's Grooming Preferences
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and care in a manner that promoted quality of life. The resident, who had severely impaired cognition and required extensive assistance with dressing, toileting, and personal hygiene, had a haircut performed by the facility staff without the family's consent. The resident's daughter had previously arranged for a specific hairdresser to cut the resident's hair and had instructed the facility to notify her if the resident needed a haircut. However, the staff, who were relatively new to the unit, were unaware of this arrangement and proceeded to cut the resident's hair to make them presentable for Thanksgiving. This action led to dissatisfaction and a grievance filed by the family, as the resident's head was buzzed against the family's wishes. The social services director confirmed that the family had not requested the haircut and that the facility did not notify the family before cutting the resident's hair. The director also mentioned that the staff was educated afterward. The resident's daughter expressed her frustration, stating that the facility had cut the resident's hair before without authorization and that the resident did not look good after the haircut. The facility's baseline plan of care indicated that the daughter should be contacted for any changes in care or treatment, including grooming and personal hygiene assistance, which was not followed in this instance.
Failure to Follow Grievance Procedure for Missing Items
Penalty
Summary
The facility failed to follow its grievance procedure for a resident who reported missing items upon discharge. The resident's representative reported the missing items, which included swim shoes, two white shirts, a pair of pajamas, and a glasses case, to the social services director at the time of discharge. Although one shirt was found and returned, the other items remained missing, and the facility did not contact the resident's representative for resolution. The grievance log for February and March 2024 showed no evidence of a grievance related to the missing items. The social services director confirmed that he was notified about the missing items after the resident's discharge but did not complete a grievance form because the facility was still looking for the items and the resident's representative was aware. The facility's grievance policy requires that when an immediate resolution is not possible, the grievance should be routed to the Grievance Official and/or Social Services/designee within 24 hours, and a grievance form should be filled out. The policy also states that the person with the grievance has a right to a written decision regarding their grievance, and the grievance forms should be logged on the grievance log.
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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