Wyoming Veterans' Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo, Wyoming.
- Location
- 700 Veteran's Lane, Buffalo, Wyoming 82834
- CMS Provider Number
- 535061
- Inspections on file
- 6
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Wyoming Veterans' Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident with hemiplegia, intact cognition, and need for assistance with toileting experienced physical and verbal abuse from a CNA during incontinence care. After the resident requested help, one CNA transferred the resident to a shower chair and a second CNA insisted on a shower despite the resident’s refusal, leading to an argument. The abusive CNA yelled, used profanity, made demeaning comments about the resident’s feces, scrubbed the resident and a wound roughly while the resident reported pain and asked her to stop, and allegedly positioned the shower chair to block access to the call light. Another CNA witnessed the yelling and rough care and heard the abusive statements. The CNA later admitted to using profanity and derogatory language. A nurse eventually entered and told the CNA to stop, ending the interaction. The DON acknowledged the incident as a concern and confirmed expectations that staff intervene and report abuse, while the facility’s abuse policy states that no abuse or harm will be tolerated.
Surveyors found that food safety standards were not followed when a dietary manager stored a personal cow hide in a black plastic bag on the floor of a warehouse walk-in freezer that also contained food for resident consumption. The hide was later observed to be frozen, with visible hair and ice accumulation, and was not stored at least 6 inches off the floor as required by the FDA Food Code. The administrator reported prior awareness of the hide’s presence and had previously instructed its removal, but was unsure if it had been removed and then returned, contrary to facility policy and food code requirements for preventing contamination.
The facility failed to submit mandatory direct care staffing data to CMS through the Payroll Based Journal (PBJ) system for three consecutive fiscal quarters while caring for 24 residents. PBJ staffing reports for fiscal year 2025 quarters 2, 3, and 4 each showed the facility triggered the metric “Failed to Submit Data for the Quarter.” In an interview, the DON acknowledged awareness that PBJ reporting was inconsistent and reported that the previous HR director had inconsistent access to the PBJ reporting system, which contributed to the lack of required staffing data submission.
A resident with anxiety, insomnia, chronic pain, muscle weakness, and a history of CVA/TIA was ordered PRN Ativan 0.5 mg every six hours for anxiety without a documented stop date. A pharmacist’s monthly medication review recommended limiting non-antipsychotic psychotropic medications to 14 days, but the physician declined the recommendation and deferred to mental health, and no rationale for extended use or stop date was documented. The DON stated that staff were expected to follow up on monthly medication review orders kept in a binder, yet no further follow-up occurred, despite facility policy directing the prescriber and DON to act on recommendations from monthly regimen reviews.
A resident was involuntarily discharged without the facility providing a written discharge notice or completing discharge planning, as confirmed by review of progress notes and an interview with the DON. Facility policy required the Social Services Manager or designee to give written transfer or discharge notice to the veteran, the family or legal representative, and the State LTC Ombudsman, with 30 days’ notice for community-initiated transfers or discharges except in emergencies. These policy requirements were not followed in this case.
The facility failed to complete required PASRR screenings and evaluations for multiple residents with documented mental health diagnoses. One resident with moderate cognitive impairment, depression, and schizophrenia had no PASRR Level I or Level II documented in the record. Another resident with schizoaffective disorder had a PASRR Level I that concluded there was no evidence of mental illness, and although this resident consented to a PASRR Level II, no completed Level II was found in the record. A third resident with PTSD and schizophrenia had a PASRR Level I indicating evidence of mental illness and the need for a PASRR Level II, but no Level II was documented. The DON confirmed that PASRR Level II assessments should have been completed and reported that the staff member responsible had been locked out of the PASRR system, despite a facility policy requiring appropriate state determinations prior to admission for individuals with mental disorders or intellectual disabilities.
A deficiency occurred when a pharmacy’s monthly drug regimen review recommended discontinuation of hydroxyzine 25 mg PRN for anxiety for a resident, and the physician accepted this recommendation and ordered the medication discontinued, but the order was not carried out. Review of the physician orders showed the hydroxyzine remained active, and the DON confirmed it had not been discontinued. This was inconsistent with the facility’s “Interim Medication Regimen Review” policy, which requires the physician/prescriber to accept and act upon recommendations from the monthly medication review.
Surveyors found that in one cottage, an opened and partially used Insulin Glargine pen was stored without any indication of the date it was first used. An RN confirmed the pen had been used and acknowledged that insulin pens are required to be labeled with the opened date. The DON also confirmed that staff are expected to label multi-dose insulin with the date of opening. Review of facility policy showed all multi-dose vials must be dated and assigned a 28-day expiration at first use, and manufacturer instructions specified the pen should only be used for up to 28 days after first use, demonstrating that the undated insulin pen was not handled according to required procedures.
A resident who had previously received PCV13 and consented to a pneumonia vaccine at admission did not receive the planned PCV20 dose, despite documentation that it was to be administered and a facility policy requiring assessment and provision of the pneumococcal vaccine series within 30 days of admission in accordance with CDC recommendations. Medical record review showed no documentation of vaccine administration, and the Infection Preventionist confirmed the vaccine was not given.
Failure to Protect Resident From Physical and Verbal Abuse During Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical and verbal abuse by a CNA during personal care. The resident had hemiplegia/hemiparesis with upper and lower extremity impairment on one side and required partial/moderate assistance with toilet hygiene and transfers. During an episode of incontinence, the resident used the call light for help and was assisted by one CNA into a shower chair in the bathroom. A second CNA (CNA #1) then became involved in the care and insisted the resident take a shower, which the resident refused, leading to an escalating argument. According to the resident, CNA #1 yelled and cursed, scrubbed the resident very hard, was intentionally rough, and continued despite the resident’s reports of pain and requests to stop and get another caregiver. The resident reported that CNA #1 locked the shower chair brakes to prevent access to the call light and that the interaction caused pain during the incident and soreness afterward. Another CNA (CNA #2) reported hearing CNA #1 yelling and arguing with the resident, observed her scrubbing the resident and a wound while the resident said it hurt and asked her to stop, and heard CNA #1 refuse to stop. CNA #2 also reported hearing CNA #1 call the resident an “asshole” and state that the resident had “shit” in the genital area. CNA #1 acknowledged telling the resident they needed to get the “shit” off and admitted saying that if the resident was going to be an “ass,” she could be an “ass” too. CNA #1 described the resident yelling and kicking during care and stated she sprayed the resident with cold water accidentally, then began washing the resident and stopped when asked, but her account conflicted with the resident’s and CNA #2’s reports that she continued despite the resident’s objections. A nurse entered the room during the incident and told CNA #1 to stop talking to the resident, which ended the interaction. The DON later stated she considered the incident a concern and that staff who witness abuse are expected to intervene and report immediately, and it was noted that no formal plan of correction was implemented following this incident, despite the facility’s written abuse policy stating that no abuse or harm of any type will be tolerated and that veterans will be protected from abuse, neglect, and harm.
Improper Storage of Personal Cow Hide in Walk-In Freezer Used for Resident Food
Penalty
Summary
Surveyors observed that food was not stored in accordance with professional standards for food service safety in the facility’s warehouse walk-in freezer. During an observation, a black plastic bag was seen on the freezer floor near the entry door. The dietary manager stated the bag contained a cow hide that was his personal item and acknowledged that other items in the freezer were for resident consumption. Later observation showed the dietary manager opening the bag, revealing a frozen cow hide with black hair, folded and covered with ice on the flesh and hair. The hide was stored directly on the freezer floor, not elevated as required. The facility administrator reported he had been aware of the cow hide being stored in the freezer months earlier and had instructed the dietary manager to remove it, believing it had been taken out. He was unsure whether the hide had been removed and then returned to the freezer. Facility policy on food preparation and storage required protection of food from contamination or cross-contamination in accordance with the current food code, including proper storage and handling. The 2022 FDA Food Code requires food to be stored in a clean, dry location, protected from contamination, and at least 6 inches above the floor, which was not followed in this instance.
Failure to Submit Required Payroll Based Journal Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system as required. Review of the PBJ staffing reports for fiscal year 2025 quarter 2 (January 1–March 31), quarter 3 (April 1–June 30), and quarter 4 (July 1–September 30) showed the facility triggered the metric “Failed to Submit Data for the Quarter” for each of these three consecutive quarters, during which the census was 24. In an interview, the DON stated the facility was aware that PBJ reporting was not consistent and further explained that the previous HR director had inconsistent access to the PBJ reporting system, contributing to the failure to submit the mandatory staffing data.
Failure to Limit PRN Psychotropic Medication to 14 Days and Act on Pharmacist Review
Penalty
Summary
Surveyors identified a failure to limit an as-needed psychotropic medication to 14 days for one resident. The resident had a BIMS score of 15/15, indicating intact cognition, and diagnoses including anxiety disorder, insomnia, chronic pain, muscle weakness, and a history of cerebrovascular accident or transient ischemic attack. Physician orders dated 12/8/25 showed the resident was receiving Ativan 0.5 mg every six hours as needed for anxiety without any documented stop date. A monthly medication review dated 12/29/25 documented that the pharmacist recommended limiting non-antipsychotic psychotropic medications to 14 days, but the physician declined this recommendation and deferred the issue to mental health, and the medical record contained no physician rationale for extended use or a stop date. The DON reported that staff were expected to follow up on monthly medication review orders placed in a binder at the nursing station, but there was no additional follow-up on the pharmacist’s recommendation by nursing or mental health services, despite facility policy stating that the physician/prescriber and DON should act upon recommendations in the monthly regimen reviews. This resulted in the continued use of an as-needed psychotropic medication without adherence to the 14-day limitation or documented justification for extended use, contrary to the facility’s medication regimen review policy.
Failure to Provide Required Written Notice and Discharge Planning for Involuntary Discharge
Penalty
Summary
The facility failed to provide required written discharge notice and conduct discharge planning for a resident who was involuntarily discharged. Medical record review showed a progress note dated 10/28/25 at 1:05 PM documenting that resident #24 was involuntarily discharged from the facility, but further review of the progress notes revealed no evidence that a written discharge notice was given to the resident or the resident’s representative, nor that discharge planning was completed prior to the discharge. In an interview on 1/22/26 at 4:26 PM, the DON confirmed that no written discharge notice was issued and no discharge planning was performed before the resident left the facility. Review of the facility’s policy titled “Transfer or discharge,” dated 12/4/23, showed that the WVSN Social Services Manager, or designee, is responsible for providing the veteran and family member or legal representative, and the Office of the State Long-Term Care Ombudsman, with a notice of transfer or discharge, and that notice of community-initiated transfer or discharge is to be provided 30 days before transfer or discharge unless there is an emergency transfer. The documentation and interview findings demonstrated that these policy requirements were not followed for this involuntary discharge.
Failure to Complete Required PASRR Level I and Level II Evaluations for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASRR) Level I and Level II evaluations were completed for residents with mental disorders or intellectual disabilities. One resident with moderate cognitive impairment and diagnoses including depression and schizophrenia had no evidence in the medical record that any PASRR screening was completed prior to or following admission in July 2025, which was confirmed by the DON. For a second resident with a diagnosis of schizoaffective disorder, the PASRR Level I dated 9/18/25 documented responses of “no” to questions regarding major mental illness, history of mental illness requiring more than outpatient treatment in the past two years, and current evidence of mental illness, and the Level I summary concluded there was no evidence of mental illness or intellectual disability, despite the documented schizoaffective disorder diagnosis. A third resident had a PASRR Level I dated 11/6/25 showing diagnoses including PTSD and schizophrenia, and the Level I summary indicated there was evidence of mental illness and that a PASRR Level II was required. For both the second and third residents, the medical records contained no evidence that the required PASRR Level II assessments were completed, even though one resident had signed a PASRR Level II informed consent form dated 10/14/25. In an interview, the DON confirmed that PASRR Level II assessments should have been completed for these two residents and stated that the staff member responsible for completing the assessments had been locked out of the PASRR system. The facility’s PASARR policy stated that the community would not admit new veterans with mental disorder or intellectual disability unless the appropriate state authority had made the required determinations prior to admission, but the documented screenings and missing Level II assessments did not align with these requirements.
Failure to Discontinue Medication After Accepted Pharmacy Recommendation
Penalty
Summary
The deficiency involves the facility’s failure to act on a pharmacy recommendation and corresponding physician order to discontinue an unnecessary medication for one resident. A monthly medication regimen review for December 2025 documented that the consulting pharmacy recommended discontinuing hydroxyzine 25 mg, ordered as needed for anxiety. The medical record showed that the physician accepted this recommendation and ordered the hydroxyzine to be discontinued. However, review of the physician orders revealed that the hydroxyzine order remained active and had not been discontinued. In an interview on 1/23/26 at 8:30 AM, the DON confirmed that the medication had not been discontinued. Review of the facility’s policy, “Interim Medication Regimen Review” (last updated 2018), showed that the physician/prescriber should accept and act upon recommendations contained within the monthly medication review, which did not occur in this case. This failure to implement the accepted pharmacy recommendation and physician order for discontinuation of hydroxyzine for anxiety constituted noncompliance with the facility’s own policy and procedures for monthly drug regimen review and unnecessary medications.
Failure to Date Opened Insulin Pen per Policy and Manufacturer Instructions
Penalty
Summary
Surveyors identified a deficiency in medication labeling and dating practices when, during observation in the Cottonwood cottage, an opened and partially used Insulin Glargine 100 unit/mL pen was found without a date indicating when it had been first used. At the time of observation, an RN confirmed that the insulin pen had been used and acknowledged that insulin pens were expected to be labeled with the date they were opened. The DON later confirmed that staff were expected to label multi-dose insulin with the date of opening. Review of the facility’s policy titled “Multidose Vial Use” dated August 2024 showed that all multi-dose vials must be dated with a 28‑day expiration date and labeled with the expiration date at the time of original opening by the person initially accessing the vial. Additionally, review of the insulin manufacturer’s prescribing information, last revised in 2025, indicated that the pen should only be used for up to 28 days after first use, further underscoring that the undated, opened insulin pen was not in compliance with established labeling requirements. No specific resident, medical history, or clinical condition was described in relation to the use of this insulin pen; the deficiency centered on the facility’s failure to label a multi-dose insulin pen with the date it was opened, contrary to facility policy and manufacturer instructions.
Failure to Administer Indicated Pneumococcal Vaccination After Consent and Policy Requirements
Penalty
Summary
The facility failed to ensure a resident was immunized for pneumococcal disease in accordance with its own policies and current CDC recommendations. Medical record review showed the resident’s most recent Pneumococcal Conjugate Vaccine (PCV13) was administered on 10/18/19, and the facility documented a plan to administer Prevnar 20 at the time of admission in July 2025, but there was no record that this vaccine was actually given. A vaccine consent form dated 7/9/25 showed the resident had consented to receive the pneumonia vaccine. In an interview on 1/23/26 at 10:00 AM, the Infection Preventionist confirmed the resident did not receive the planned vaccine. The facility’s written policy, dated 12/2023, required that veterans be assessed for eligibility for the pneumococcal vaccine series prior to or upon admission and, when indicated, be offered the vaccine series within 30 days of admission, with administration to follow current CDC recommendations. CDC guidance in effect at the time stated that adults over a specified age who previously received one dose of PCV13 should receive one dose of PCV20 or PCV21 at least one year after the last PCV13 dose, which had not occurred for this resident.
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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