Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Worland Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to Assess Residents With Change of Condition: The facility did not complete required assessments for multiple residents who developed acute changes such as AMS, SOB, vomiting, diarrhea, low O2 sats, decreased PO intake, and decreased urine output. One resident with stroke, renal disease, and seizure disorder was transferred with no further nursing assessment and later died after sepsis and colonic ischemia; another resident with severe dementia had emesis, lethargy, and hypoxia without timely assessment or documented intervention. Staff interviews confirmed missing assessments, missing VS, and delayed follow-up for several residents.
Missing and Unresolved Grievances: The facility did not consistently receive, document, or resolve grievances involving residents and family members. A resident’s representative reported complaints about meds, staffing, and a care mtg request without a written resolution, while staff described the DON speaking harshly and yelling at family members. Other grievances involving rude DON behavior, a resident wanting hospital transfer, and concerns about meds and VS were reported by staff but could not be produced or were not found by the administrator, despite a policy requiring prompt routing, a written decision, and record retention.
Failure to Provide Bed Hold and Transfer Notices: Staff failed to provide written bed hold and transfer notices for multiple residents who were sent to the hospital for issues including low O2 sats, SOB, GI symptoms, syncopal episode, abdominal pain, and Foley catheter problems. Several residents had significant diagnoses such as stroke, COPD, vascular dementia, hemiplegia, and respiratory failure, and the RN manager and DON confirmed the notices were not provided to residents or their representatives.
A resident with acute on chronic respiratory failure, CHF, pneumonia, pulmonary HTN, pleural effusion, and OSA arrived on 6 LPM O2 and had orders for O2, Bipap at HS, mask rinsing, and SOB assessments, but documentation showed no oxygen or Bipap placement, no mask care, and no SOB assessment until later. The resident’s representative reported the Bipap was not available on arrival and had to be set up by family, and the DON and regional nurse manager confirmed the resident went without respiratory assessment and assistance from arrival until the evening when it was first documented.
A resident with CHF, pulmonary HTN, respiratory failure, pneumonia, pleural effusion, urine retention, and OSA was admitted with orders for sildenafil, tamsulosin, apixaban, metoprolol, and pantoprazole. Pharmacy processing was delayed because the orders were stuck in queue, and the MAR showed missed doses of multiple meds after admission. The resident's rep, social services director, DON, and regional nurse manager confirmed the resident went without ordered meds until late the next day, with some meds given later and the rest the following day.
A resident with pulmonary HTN, CHF, respiratory failure, and other diagnoses did not receive ordered sildenafil and metoprolol on schedule after arrival. MAR review showed multiple missed doses, and the meds were not entered into the system until later, delaying administration. The resident's representative and the social services director reported the missed meds, and the DON and regional nurse manager confirmed the resident was without meds from arrival until the next day, with an elevated pulse documented and no reassessment noted.
A resident with chronic kidney disease, HTN, and atherosclerotic heart disease was found with an unlabeled cup containing an unmarked white pill after a traveling nurse had previously offered what the resident described as a sodium chloride “salt pill” instead of the prescribed sodium bicarbonate for acute kidney failure. The resident refused the pill, but the nurse reportedly stated it made no difference and left the medication behind. Record review showed no order for sodium chloride and no self-administration assessment. The DON could not verify what the pill was, when it was given, or if it was documented on the MAR, and the regional clinical nursing director acknowledged there was no facility policy on medication administration.
Staff failed to follow infection prevention and control practices for handling contaminated laundry on one unit. A CNA was observed leaving a room carrying unbagged, soiled bed linens down the hallway and placing them directly into a dirty linen bin instead of bagging them inside the room. In an interview, the DON confirmed that soiled linens are required to be bagged before leaving the room, and the facility’s “Soiled Laundry and Bedding” policy states that contaminated laundry must be placed and transported in bags or containers according to established handling and disposal procedures.
A resident with severe cognitive impairment and a history of dementia, anxiety, and depression had increasing right leg pain, swelling, discoloration, and deformity over a period of weeks, repeatedly reported by CNAs to nursing staff and treated with pain medication. On one evening, an LPN and the DON noted new or worsening edema, bruising, visible deformity, decreased ROM, and non–weight-bearing status of the right lower extremity, and the provider ordered transfer to the ER, where a right femur fracture was identified. Although the injury was recognized as an injury of unknown source and administrative staff were notified, the facility’s incident report to the State Agency was not submitted until many hours later, exceeding the policy requirement to report such allegations within 2 hours when they involve abuse or result in serious bodily injury.
A resident with CHF, UTI, mild cognitive impairment, and other conditions was admitted for skilled rehab and nursing care with a physician-certified 30‑day stay and a recommendation for post‑SNF care at an ALF. A care conference set an approximate discharge in about 10 days, and an LPN documented that discharge orders were received and carried out, with stable vital signs, discharge instructions, and medications provided before the resident left via personal transport. Subsequent interviews with the NP, SSD, NHA, and regional clinical director revealed that no provider had actually issued or signed discharge orders, there was no discharge visit, no scheduled follow‑up physician visit, and no written PT/OT orders, and that staff only realized after the resident left that the physician had not been contacted, resulting in the resident being discharged without proper provider authorization.
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 reported $200 missing from their bedside table, but the facility failed to report the allegation to the state survey agency as required by their policy. The resident, who was cognitively intact, informed the social services director, but the investigation was not reported, violating the facility's reporting policy.
A resident with dementia and behavioral symptoms was not engaged in activities as per their care plan, despite the facility's policy to provide resident-centered activities. Observations showed the resident pacing and not being assisted to participate in scheduled activities. The facility was short-staffed, affecting the implementation of the activities program.
A facility failed to follow the dietary orders for a resident with diabetes, serving a full cinnamon roll with glaze instead of the prescribed half portion without glaze. The resident, who was cognitively intact, confirmed the deviation from the diabetic diet plan. Interviews with the dietitian and dietary manager highlighted that the facility's protocol requires adherence to diet cards unless a resident requests otherwise, which was not the case here.
A facility failed to implement proper infection prevention practices during care for a cognitively impaired resident. A CNA, while assisting with incontinence care, did not change gloves before touching clean items and handled soiled laundry without bagging it. Interviews confirmed the CNA knew the correct procedures but was nervous, leading to the breach.
A resident with severe cognitive impairment and dementia was physically abused by another resident with similar impairments, resulting in a scalp laceration and severe pelvic fracture. The incident occurred after both residents were in the dining room and later assisted to their rooms. The perpetrator had recently undergone a dose reduction of antipsychotic medication.
Failure to Assess Residents With Changes in Condition
Penalty
Summary
The facility failed to ensure assessments were performed for multiple residents who had changes in condition, including residents with altered mental status, respiratory symptoms, vomiting, diarrhea, decreased oral intake, abnormal vital signs, decreased urine output, and other acute changes. The report states that for 7 of 9 sampled residents reviewed for change of condition, the facility did not complete the expected assessments, and this resulted in actual harm to two residents who experienced delays in treatment. One resident with a history of stroke, anemia, hypertension, renal disease, hemiplegia, and seizure disorder developed nausea, dark tarry stool, weakness, and decreased responsiveness before transfer to the hospital. The record showed no additional nursing assessments before transfer, and the hospital documented sepsis, altered mental status, abdominal pain, prolonged QT interval, and nonsustained ventricular tachycardia. The resident later deteriorated with hypotension, worsening lactic acidosis, and colonic ischemia, and died after the family declined surgery and chose comfort care. The record also showed no head-to-toe nursing assessments since a prior change of condition months earlier, and staff interviews described earlier complaints of headache, crying, poor intake, sleeping more, and staring spells that were reported but not documented as an assessment. Another resident with severe vascular dementia, cognitive communication deficit, macular degeneration, peripheral vascular disease, hypertension, and depression had emesis, coughing during meals, lethargy, diminished lung sounds, and low oxygen saturation. The record showed no physical assessment or intervention documented with the initial vomiting episode, no evidence of reassessment when the resident became difficult to awaken with oxygen saturation of 87% on room air, and no evidence of a comfort care order until later even though the resident was documented as being on comfort measures before that order was obtained. The resident later expired. Similar failures were documented for other residents, including shortness of breath with low oxygen saturation, vomiting and diarrhea without assessment, decreased urine output with blood in the catheter output, and a new admission whose medications were delayed and whose elevated heart rate lacked documented follow-up assessment.
Missing and Unresolved Grievances
Penalty
Summary
The facility failed to properly obtain, track, and maintain grievances and failed to maintain evidence of appropriate action and written grievance decisions for multiple residents and family members. The report states that grievances were not consistently received by the administrator, were sometimes given to the DON or other staff without being formally documented, and in several instances could not be produced during the survey. The facility policy required grievances to be routed promptly, responded to within five business days, and maintained for at least three years, but the survey found missing grievance records and no evidence that the required written decisions were issued in several cases. For one resident, the resident’s representative reported filing grievances about medications, staffing, and a requested care meeting, but stated no resolution was provided and that the DON was rude after the grievances were filed. Documentation showed the DON wrote notes about the family’s requests and stated the family would not be meeting until the following week, while another note showed the family had left a handwritten request for the DON and/or management. The administrator stated she did not receive either grievance or any request for a meeting. Staff interviews described witnessing the DON yelling at the resident’s family in front of others, and the human resources director confirmed she had heard complaints about the DON but had not made formal complaints because she was unaware of a protocol for doing so. For another resident, a grievance form documented that the DON had approached the resident’s roommate in a rude manner regarding mask use, and the listed resolution was that the DON would identify herself before assessing the roommate. However, staff reported that the DON attempted to handle the grievance herself, that the administrator asked for the grievance to be rewritten, and that the DON later confronted the resident in the room while denying the accusation. The administrator stated she did not address the DON’s behavior on the grievance form and did not interview any witnesses. Additional grievances described by staff and the social services director, including concerns about a resident wanting hospital transfer, a resident not receiving medications or vital signs, and other missing grievances, were also not found by the administrator or could not be produced by the facility.
Failure to Provide Bed Hold and Transfer Notices
Penalty
Summary
The facility failed to ensure written bed hold and transfer notices were provided for 6 of 7 residents reviewed for transfers. Resident #4 had a BIMS score of 15/15 and diagnoses including stroke, anemia, hypertension, renal disease, hemiplegia, and seizure disorder; after a syncopal episode with black tarry stools, the resident was sent to the ED, and there was no evidence that a bed hold or transfer notice had been provided. Resident #6 had a BIMS score of 14/15 and diagnoses including COPD, anemia, hypertension, acute on chronic respiratory failure with hypoxia, malnutrition, and pulmonary fibrosis; after low oxygen saturation readings, the resident was transferred to the hospital, the bed hold was incomplete, and there was no evidence of a transfer notice. Resident #3 had a BIMS score of 13/15 and diagnoses including right-sided hemiplegia, hypertension, peripheral vascular disease, respiratory failure with hypoxia, dysphagia, and encephalopathy; the resident was sent to the hospital for shortness of breath and later for vomiting and diarrhea, with no evidence of a bed hold or transfer notice for either transfer. Resident #7 had moderate cognitive impairment with diagnoses including obstructive and reflux uropathy, urine retention, and seizure disorder, and was sent to the hospital for abdominal pain and Foley catheter issues without a bed hold or transfer notice. Resident #2 had a BIMS score of 99 and diagnoses including stroke, hemiplegia, aphasia, apraxia, atrial fibrillation, and hypertension; after being sent to the hospital for low oxygen saturation readings, there was no evidence of a bed hold or transfer notice. Resident #5 had severe cognitive impairment with diagnoses including vascular dementia, hypertension, diabetes, cerebral vascular accident, depression, and need for assistance with personal care; staff followed up with the hospital about the resident's status, but there was no documentation that the resident had been transferred or of the resident's condition before transfer, and no bed hold or transfer notice was found. Interview with the regional nurse manager and DON confirmed that no bed holds or transfer notices had been provided to the residents or their representatives.
Failure to Provide Ordered Respiratory Care on Admission
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with acute on chronic respiratory failure with hypercapnia and hypoxia, congestive heart failure, pneumonia, pulmonary hypertension, pleural effusion, and obstructive sleep apnea. The resident’s discharge MDS showed a BIMS score of 13, indicating the resident was cognitively intact. On admission, the resident arrived on 6 LPM of oxygen via nasal cannula, and an order placed on 5/5/26 directed oxygen at 6 L/min via nasal cannula with titration to keep oxygen saturation above 90%. However, there was no evidence of oxygen placement or assessment on 5/4/26 or the morning of 5/5/26. There was also no evidence of Bipap placement or assessment on 5/4/26, and no evidence that the ordered morning rinse of the mask had been completed on 5/5/26. In addition, the order to assess whether the resident became short of breath when lying flat or avoided lying flat to prevent shortness of breath had no documented assessment on 5/4/26 or the morning of 5/5/26. A progress note stated the resident arrived as a new admission on 5/4/26, but the medication orders were stuck in the pharmacy queue and were not processed until 5/5/26, so the resident did not receive medications the prior night or that morning. The resident’s representative reported that the resident arrived around 11:30 AM on 5/4/26, did not have a Bipap available when she visited at 4 PM, and she had to obtain the resident’s Bipap and set it up herself because staff did not assist. The social services director stated the family contacted her on the evening of 5/5/26 about the respiratory orders not being provided, and she found no documentation that anything had been done. The regional nurse manager and DON confirmed the resident was without respiratory assessment and assistance from arrival until the evening of 5/5/26, when assistance and assessment were first documented.
Medication Orders Not Started Promptly After Admission
Penalty
Summary
The facility failed to ensure pharmaceutical services were carried out to meet the needs of a resident by accurately acquiring, receiving, dispensing, and administering ordered medications. The resident had a discharge MDS showing a BIMS score of 13/15 and diagnoses including acute on chronic respiratory failure with hypercapnia and hypoxia, CHF, pneumonia, pulmonary hypertension, pleural effusion, urine retention, and obstructive sleep apnea. Physician orders included sildenafil citrate 20 mg three times daily, tamsulosin 0.4 mg each morning, apixaban 2.5 mg twice daily, metoprolol tartrate 12.5 mg twice daily, and pantoprazole 40 mg each morning. A progress note stated the resident arrived as a new admission and the medication orders were entered into PCC for pharmacy processing, but the medications were stuck in queue and were not processed until the next day. The note also stated the resident did not receive medications the prior night or that morning. The MAR showed no evidence that sildenafil, tamsulosin, apixaban, metoprolol, or pantoprazole were administered as ordered during the first days after admission. The resident's representative reported the resident did not receive any medications until late in the evening after arrival, and the social services director, DON, and regional nurse manager confirmed the resident was without medications from arrival until the evening of the following day, with some medications given then and the rest given the next day.
Missed Scheduled Medications for Resident With Pulmonary Hypertension
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when ordered medications were not administered as prescribed after the resident arrived at the facility. The resident had a BIMS score of 13 out of 15 and diagnoses including acute on chronic respiratory failure with hypercapnia and hypoxia, CHF, pneumonia, pulmonary hypertension, pleural effusion, urine retention, and obstructive sleep apnea. Physician orders included sildenafil citrate 20 mg by mouth three times daily and metoprolol tartrate 12.5 mg by mouth twice daily related to pulmonary hypertension, along with tamsulosin HCl. Review of the MAR showed no evidence the resident received sildenafil on the evening of arrival or during multiple scheduled doses the next day, and no evidence the resident received metoprolol on the evening of arrival or the next morning. Documentation showed the medications were not entered into the system until the evening after the resident had already been at the facility, and the first administration did not occur until after they were logged in. A progress note documented an elevated pulse of 119 beats per minute, with no evidence the pulse was reassessed. The resident's representative and the social services director both reported contacting the facility about the missed medications, and the social services director stated she did not see documentation that anything had been done before notifying the DON. The regional nurse manager and DON confirmed the resident was without medications from arrival until the evening of the next day, with some medications given then and the rest the following day. Manufacturer information reviewed for metoprolol noted abrupt cessation of therapy can cause exacerbations of angina and, in some cases, myocardial infarction, and literature on sildenafil cessation in pulmonary hypertension noted missed doses can cause increased shortness of breath, fatigue, dizziness, or lightheadedness.
Unlabeled and Unverified Medication Left in Resident’s Possession
Penalty
Summary
Surveyors identified a failure to ensure safe storage and proper labeling of medications for one resident reviewed for medication administration. Observation showed the resident had an unlabeled medication cup containing one unmarked white pill. The resident reported that a traveling nurse had given a sodium chloride “salt pill” a few months earlier, even though the resident knew they were prescribed sodium bicarbonate and refused to take the pill after noticing the difference. The resident stated the nurse told them it did not make a difference and that it did the same thing, and that the nurse left the medication behind after the resident refused it. Review of the medical record showed the resident had diagnoses including chronic kidney disease, hypertension, and atherosclerotic heart disease, and had a physician’s order for sodium bicarbonate 325 mg, two tablets by mouth twice daily for acute kidney failure, with no order for sodium chloride. There was no evidence of a self-administration of medication assessment in the record. The DON stated the medication in the resident’s possession was an OTC medication but was unable to verify what it was, when it was provided, or whether it had been documented on the MAR, and confirmed she expected nurses to watch residents take their medications. The regional clinical nursing director reported that the facility did not have a policy on medication administration.
Failure to Bag and Contain Soiled Linens Before Transport
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for handling soiled linens on one of four units. On 4/30/26 at 6:01 AM, a CNA was observed exiting a resident room carrying unbagged, soiled bed linens in her hands, walking down the hallway, and placing the soiled linens directly into the dirty linen bin without first bagging them inside the room. In an interview later that morning, the DON confirmed that facility practice requires soiled linens to be placed in a bag before leaving the resident’s room. Review of the facility’s policy titled “Soiled Laundry and Bedding,” last revised in February 2026, showed that contaminated laundry is to be placed and transported in bags or containers in accordance with established policies governing the handling and disposal of contaminated items. This deviation from both staff-stated practice and written policy regarding the handling and transport of contaminated laundry constituted a failure to implement the facility’s infection prevention and control program on the affected unit.
Failure to Timely Report Injury of Unknown Source Involving Suspected Fracture
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown source to the State Agency within 2 hours as required by policy. A resident with non-Alzheimer’s dementia, anxiety, depression, and a BIMS score of 0 indicating severe cognitive impairment was noted on a quarterly MDS to have had no falls since admission or the prior assessment. On the evening in question, a progress note documented new or worsening edema and a change in skin color/condition of the resident’s right lower extremity, and the PCP recommended transfer to the ER for an x-ray to rule out fractures. Shortly thereafter, another progress note described mild bruising, visible swelling, and inward deformity of the right knee, with notification of the DON and MD and a recommendation to send the resident to the ER. The following day, the DON documented increased swelling and pain on touch, decreased ROM, non–weight-bearing status of the right lower extremity, and no open areas, with an order from the provider to send the resident to the ER to rule out fracture or dislocation of the right knee. The SSD reported that the DON notified administrative staff of the right knee injury at the morning staff meeting and that the SSD accompanied the resident and POA to the ER, where a right femur fracture was identified and communicated back to facility administration. The SSD further reported that an APS caseworker arrived later that day and stated she had not received a report from the facility, and the SSD was instructed to open the report. Review of the facility’s FRI showed the allegation of injury of unknown source occurred at 9:40 PM, staff and the administrator were made aware at 9:43 PM, but the initial incident report was not sent to the State Agency until 9:05 PM the following day, exceeding the 2-hour reporting requirement. Interviews with multiple CNAs indicated the resident had complained of pain and exhibited abnormal right knee findings for an extended period prior to the ER transfer. One CNA stated the resident had complained of pain for approximately two weeks and that she reported it to nurses daily. Another CNA reported that for about three weeks the resident’s right knee had been swollen, discolored with greenish-purplish bruising, and not normal, and that she informed nurses who responded they would give pain medication. A third CNA recalled the resident in mid-February moaning, groaning, and stating the leg was broken, which she reported to a nurse who then provided pain medication. A fourth CNA described the resident crying out in pain on the night of the incident, with the right leg appearing larger, bent, and discolored after transfer with a hoyer lift, which she reported to the nurse. LPN interview confirmed increased yelling out in pain that evening, subsequent discovery of the visibly deformed knee after CNA report, and notification of the DON, resident representative, and physician. Despite these findings and the facility policy requiring immediate reporting, but no later than 2 hours, of all allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source that involve abuse or result in serious bodily injury, the facility did not report the injury of unknown source within the required timeframe.
Resident Discharged Without Provider-Signed Orders or Follow-Up Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident admitted for skilled rehabilitation and nursing care. The resident had diagnoses including nontraumatic hematoma of soft tissue, CHF, UTI, and mild cognitive impairment, and had been certified by the physician for a 30‑day skilled stay with a recommendation for post‑SNF care at an ALF. Care conference minutes identified an approximate discharge date of 10 days after admission. The medical record documented that the resident was discharged on 3/30/26 in the early afternoon, with an LPN note stating that discharge orders were received and carried out, vital signs were stable, discharge instructions and medications were reviewed with the resident and responsible party, and all belongings were sent with the resident, who left via personal transport in stable condition. However, interviews and documentation showed that no provider had actually issued or signed discharge orders at the time of discharge. The NP reported that the physician’s office had not received discharge orders, that the physician was out of town, and that she refused to sign requested orders for medications and therapy because she had not evaluated the resident and had not ordered the discharge. She further stated there was no discharge visit, no follow‑up physician visit scheduled, and no written PT/OT orders, and the discharge was not treated as an AMA discharge. The SSD stated staff believed they had physician orders because they had “lined everything up,” but only realized after the resident left that the physician had not been contacted, prompting a call for a narcotic prescription that the NP declined to sign. The NHA confirmed the expectation that a provider discharge order should be in place before discharge, and the regional director of clinical operations confirmed the resident was discharged without signed discharge orders.
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 Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property for one of the residents reviewed for abuse, neglect, and misappropriation. The resident, who was cognitively intact with a mental status score of 14 out of 15, reported to a housekeeper that $200 was missing from a bank envelope on their bedside table. The resident was unable to specify what happened to the money or when it went missing. Despite the resident informing the social services director about the missing money, the allegation was not reported to the state survey agency as required. The facility's policy on reporting and investigating abuse, neglect, exploitation, or misappropriation mandates that any suspicion must be reported immediately to the administrator and other officials according to state law. The policy specifies that allegations not involving abuse or serious bodily injury should be reported within 24 hours. However, the social services director confirmed that the investigation into the missing money was completed but not reported to the state survey agency, indicating a failure to adhere to the facility's policy and state reporting requirements.
Failure to Engage Resident in Activities Program
Penalty
Summary
The facility failed to provide an activities program that met the needs and preferences of a resident with dementia and behavioral symptoms. The resident, who had a history of being a janitor and enjoyed being helpful, was observed pacing and not being engaged in activities as per their care plan. The care plan indicated the resident's interest in group activities, going outside, and participating in simple, structured activities. However, observations showed the resident was not assisted to participate in scheduled activities and was left to pace around the facility. On multiple occasions, the resident was observed pacing in the dining room and hallways without being engaged in any activities. Despite the activities calendar listing various activities, the resident was not invited or assisted to join them. The resident expressed a desire to help with cleaning tasks, but staff did not facilitate this interest, leaving the resident to attempt cleaning tasks independently without proper support or guidance. The facility's policy stated that activities should be based on comprehensive resident-centered assessments and preferences, yet the resident's needs were not met. The social services director acknowledged that the facility was short-staffed due to one activities staff member being on medical leave and another on vacation, which affected the implementation of the activities program. The expectation was for CNAs to perform structured activities, but this was not observed during the survey.
Failure to Follow Diabetic Diet Orders
Penalty
Summary
The facility failed to adhere to the dietary orders for a resident with diabetes mellitus, who was on a controlled carbohydrate diet. The resident, who was cognitively intact, was supposed to receive a half portion of a cinnamon roll without glaze, as per the diet card accompanying the meal. However, during an observation, the resident was served a full cinnamon roll with glaze, contrary to the prescribed diet. The resident confirmed that the facility did not follow the diabetic diet plan. Interviews with the dietitian and dietary manager revealed that the facility's diabetic diet protocol includes smaller portions of carbohydrates and sugar, and diet cards should be strictly followed unless a resident requests a deviation. The dietary manager confirmed that any requests for different items should be noted on the diet card, and in this case, the resident did not request a full cinnamon roll or glaze. The dietary manager also stated that aides are expected to catch such discrepancies and seek nurse approval if a resident requests a full portion, which did not occur in this instance.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention practices during personal care for a resident with severe cognitive impairment and physical disabilities. The resident, who was frequently incontinent and dependent on staff for hygiene, was observed being assisted by a CNA and an OT. During the care, the CNA placed the resident's soiled pants on the floor and proceeded to perform incontinence care. Without changing gloves, the CNA touched various clean items in the room, including the resident's clean clothing and personal items, before finally removing the gloves and using hand sanitizer. The CNA then handled the soiled pants without placing them in a bag, contrary to infection control protocols. Interviews with the CNA and the infection preventionist confirmed that the CNA was aware of the expectation to remove contaminated gloves before touching clean items and to bag soiled items before leaving the resident's room. The facility's policies and CDC guidelines were reviewed, which clearly outlined the proper procedures for glove use and handling of soiled laundry. The CNA admitted to being nervous, which contributed to the failure to follow these protocols, resulting in a breach of infection prevention practices.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. The victim, who had severely impaired cognitive skills and a history of non-Alzheimer's dementia and pelvic fractures, was found on the floor of their room with a scalp laceration after being pushed by another resident. This incident occurred after both residents had been in the dining room together and were later assisted to their rooms. The perpetrator, also with severely impaired cognitive skills and a history of unspecified dementia with behavioral disturbances, entered the victim's room and admitted to pushing them down. The incident was discovered when a CNA heard a door slam and found the victim on the floor with a head injury. The victim was subsequently diagnosed with a severe pelvic fracture and exacerbation of degenerative joint disease. Interviews with staff revealed that the incident was unexpected, as the residents had been getting along well prior to the event. The perpetrator had recently undergone a gradual dose reduction of antipsychotic medication, which was increased following the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Worland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyoming Retirement Center | 24.6 mi | ★★★★★ | 7 | 0 |
| Thermopolis Rehabilitation And Wellness | 29.4 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.