Citations in Wyoming
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Wyoming.
Statistics for Wyoming (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Wyoming
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on each shift, as required.
Multiple residents with significant physical and cognitive impairments did not receive routine bathing or personal hygiene assistance for extended periods, as confirmed by interviews, medical records, and grievance forms. Residents reported missed showers and delayed care, often attributed by staff to ongoing staffing shortages, with some residents going weeks without bathing and having to escalate their requests to facility leadership.
The facility did not include the total hours worked by RNs, LPNs, and CNAs on daily nurse staffing postings, as required. Staff postings only listed individual names, positions, and hours worked, but omitted the total hours for each staff category. This was confirmed by the administrator during staff interviews.
A resident with severe cognitive impairment and multiple chronic conditions was admitted at risk for pressure ulcers but did not receive timely or documented wound care after developing several pressure ulcers. Despite physician notes and nursing evaluations identifying new ulcers, necessary treatment orders and interventions were delayed, and there was no evidence of wound care prior to the resident's discharge after being sent to the emergency room.
Staff did not follow infection control protocols, as a resident's catheter bag was repeatedly placed on the floor, and the facility failed to implement its Legionella water management program. Additionally, an outbreak of gastrointestinal illness affecting 14 residents was not reported to the state licensing agency, and the interim DON was unaware of the reporting requirement.
Three cognitively intact residents were not included in the development or implementation of their person-centered care plans, as evidenced by their lack of recall of care conference invitations and absence of documentation showing their participation, despite facility policy requiring such involvement. The DON confirmed that while care conferences were held, there was no evidence of resident participation.
The facility did not maintain documentation showing that residents were educated on the benefits and risks of the COVID-19 vaccine or that consent or refusal forms were completed, as required by facility policy. Medical record reviews and staff interviews confirmed the absence of this documentation for several residents who were not up-to-date on vaccination.
Surveyors observed that a soiled fan was blowing onto a food preparation counter where food was being handled, and a rack for clean utensils was placed near dirty pipes behind the cooking area. The fan and the area behind the grill/oven were confirmed to be unclean, and the latter was not included on the cleaning schedule.
The facility did not provide required written transfer notices or bed-hold policy information to several residents or their representatives prior to hospital transfers, and failed to notify the State LTC Ombudsman as required. Documentation of these actions was missing or incomplete, and facility policy procedures for notification and record-keeping were not followed.
Surveyors identified that MDS assessments were not accurately completed for three residents. One resident with multiple psychiatric diagnoses was incorrectly marked as not having a serious mental illness per PASRR Level II, and another resident's functional status section (GG) was left unassessed due to lack of available staff. These deficiencies were confirmed through record review and staff interviews.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Routine Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide routine bathing and assistance with activities of daily living for multiple residents who were unable to perform these tasks independently. Several residents, including those with cognitive impairments, physical disabilities, and complex medical conditions such as morbid obesity, quadriplegia, and recent trauma, experienced extended periods without bathing. Documentation and interviews revealed gaps in bathing records, with some residents going up to 23 days without a bath or shower. Residents reported dissatisfaction and discomfort due to missed bathing, and some had to escalate their requests to facility leadership to receive basic hygiene care. Staffing shortages were repeatedly cited as a reason for the lack of timely care. Resident interviews and concern forms indicated that call lights were not answered promptly, and staff communicated to residents that showers and other care could not be provided due to insufficient staffing. On at least one occasion, there were no CNAs present in the building, and no baths were given that day. Resident Council and individual grievances highlighted ongoing issues with delayed or missed care, including showers, bed changes, and assistance with personal hygiene. Facility policy required that residents be provided showers according to their requests or the facility's schedule, based on safety considerations. However, the regional clinical director confirmed that bathing was not being performed as required, and there were no additional records to support that residents received the necessary care. The failure to provide routine bathing and personal hygiene assistance was substantiated through resident and staff interviews, medical record reviews, and grievance documentation.
Failure to Document Total Nursing Staff Hours on Daily Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staffing postings included the total number and actual hours worked by RNs, LPNs, and CNAs for each shift. During the review of daily staff postings over a one-month period, it was found that while staff names, positions, and individual hours worked were documented, the postings did not display the total hours worked for each category of nursing staff. This deficiency was confirmed during an interview with the administrator, who acknowledged that the required total hours for each staff category were not included in the daily postings. The facility census at the time was 69 residents. No specific resident medical history or condition was mentioned in relation to this deficiency.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and heart failure, was admitted without any existing wounds but was identified as being at risk for pressure ulcers. Despite this risk, the facility failed to implement and document appropriate wound care and monitoring. Physician notes indicated the development of an unstageable pressure ulcer on the resident's right buttocks, but there were no corresponding treatment orders or evidence of wound care in the medical record. Subsequent nursing evaluations documented additional pressure ulcers on the resident's heels, left medial calf, and coccyx, with delayed notification and action from the nursing staff and DON. Further review revealed that orders for necessary interventions, such as the use of prevalon boots and wound care, were not added until several days after the ulcers were identified. The resident's representative reported that the resident was sent to the emergency room for another issue, where concerning pressure ulcers were found, and the resident did not return to the facility. The interim DON confirmed that there was no documentation of wound care or treatment prior to the resident's discharge, indicating a failure to provide timely and appropriate pressure ulcer prevention and treatment.
Failure to Implement Infection Control, Water Management, and Outbreak Reporting
Penalty
Summary
Staff failed to implement and maintain effective infection prevention and control practices in several areas. During observation, a resident with a catheter was found with the catheter bag lying flat on the floor on two separate occasions. A CNA stated that the bed did not have a place to hang the bag, so it was placed on the floor. Both the interim DON and ADON confirmed that catheter bags should not be placed directly on the floor. Additionally, the facility did not implement its water management program for Legionella, as required by its own policy, and failed to maintain logs or review data for trends or deficiencies. An outbreak of gastrointestinal illness involving 14 residents was not reported to the state licensing agency, despite the requirement to do so. The interim DON was unaware of the reporting requirement at the time of the survey.
Failure to Include Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to include residents in the development and implementation of their person-centered care plans for three out of five sampled residents, all of whom were assessed as cognitively intact with BIMS scores of 15 out of 15. Interviews with these residents revealed that they either did not recall being invited to care conferences or had only been invited once, despite multiple care plan revisions and assessments occurring during their stays. Medical record reviews confirmed that care conferences were either not documented as occurring at appropriate intervals or lacked evidence of resident participation. Further review of facility policy indicated that residents and/or their representatives should be included in care plan discussions at regular intervals and after significant changes, with signatures obtained to confirm participation. However, interviews with the interim DON confirmed that while care conferences were held quarterly, there was no evidence that residents participated in the planning process as required by policy. This lack of resident involvement was consistently observed across the sampled cases.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to maintain a system for documenting that residents were provided education regarding the benefits and potential side effects of the COVID-19 vaccination, as well as documentation of consent or refusal for the immunization. Medical record reviews for four sampled residents revealed that there was no evidence these individuals received education about the COVID-19 vaccine, nor was there a copy of a consent or declination form maintained in their records. Each of these residents was noted as not being up-to-date on the COVID-19 vaccination according to their most recent MDS assessments. Interviews with the interim DON and ADON confirmed that no further documentation was available to demonstrate compliance with the facility's own policy, which requires education and signed consent prior to vaccination. The policy also specifies that education should be provided in a language and format understood by the resident or their representative, and that documentation and reporting are overseen by the infection preventionist. Despite these requirements, the necessary documentation was not present for the residents reviewed.
Unsanitary Food Preparation Area and Inadequate Cleaning Practices
Penalty
Summary
The facility failed to maintain a sanitary environment in the food preparation area, as observed during surveyor visits. An upright fan, which was visibly darkened and soiled with debris, was found blowing directly onto a food preparation counter where a cutting board and knife were present. Additionally, a rack used for storing clean utensils and cookware was located directly behind the hooded gas cooking area, with visibly dirty and soiled pipes situated between the grill/oven and the storage rack. On a subsequent observation, the same unclean fan was again blowing on the food preparation area while a dietary aide was preparing individual syrup cups for residents. The dietary manager and cook confirmed the fan was not clean, and the area behind the grill/oven remained unclean. The dietary manager also confirmed that the area behind the grill/oven was not included on the cleaning schedule. No information about specific residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Provide Required Transfer Notices and Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide required written notices of transfer and information on bed-hold policies to residents and/or their representatives prior to facility-initiated hospital transfers for three out of five sampled residents. Specifically, there was no evidence that written transfer notices or bed-hold policy information were given to the residents or their representatives for multiple transfers. In some cases, the transfer notices were not signed by the facility representative, and there was no verification of receipt by the resident or responsible party. Additionally, the facility did not send copies of the transfer notices to the Office of the State Long-Term Care Ombudsman as required. Interviews with the Nursing Home Administrator confirmed the absence of documentation showing that the required notices were provided or that the Ombudsman was notified. Policy reviews indicated that the facility's procedures require written information on bed-hold practices to be provided both in advance and at the time of transfer, with documentation of attempts to notify representatives. However, these procedures were not followed, as evidenced by the lack of signed and dated copies of the notices in the residents' medical records and the failure to notify the Ombudsman.
Inaccurate MDS Assessments and Incomplete Functional Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident with a documented history of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and sleep terror, the MDS assessment incorrectly indicated that the resident was not considered by the state PASRR Level II process to have a serious mental illness, despite documentation to the contrary. This inaccuracy was confirmed by the MDS coordinator during an interview. Another resident's annual MDS assessment had section GG, which evaluates functional abilities and goals, marked as not assessed. The MDS coordinator stated that this section was dashed out because staff were not available at the time to perform the assessment. The RAI manual specifies that section GG is intended to capture important information about a resident's functional status, including self-care and mobility activities. These findings were based on medical record review, staff interviews, and reference to the MDS RAI manual.
Some of the Latest Corrective Actions taken by Facilities in Wyoming
- CNA #2 was suspended pending an investigation, an abuse allegation investigation was initiated, including resident interviews and reporting to appropriate entities, and education was provided to all staff on abuse reporting and investigation procedures. (K - F0610 - WY)
- Resident assessment was conducted, the involved CNA was suspended, the facility reported the incidents to the adult protection agency, state survey agency, and state board of nursing, and disciplinary action was taken against the perpetrators. (G - F0600 - WY)
- The facility implemented a Quality Assessment and Performance Improvement (QAPI) program addressing resident-to-resident abuse, placed the aggressive resident on increased and then one-to-one observation, provided staff training on behavior management and working with residents exhibiting aggression, and made plans to transfer the aggressive resident to another facility. (G - F0600 - WY)
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to respond to an allegation of abuse and protect a resident's right to be free from verbal abuse by a staff member. The incident involved a CNA who verbally abused a resident and attempted to physically move the resident against their will. The grievance was reported by another CNA and witnessed by an LPN, but the facility did not take immediate action to investigate or protect the resident. The abusive CNA continued to work multiple shifts following the incident, and the grievance was not logged in the facility's grievance log. Interviews with staff revealed that the incident was reported to the Business Office Manager (BOM), who asked the reporting CNA to document it in writing. Despite this, the grievance was not acted upon promptly, and the abusive CNA remained on duty. The facility's failure to investigate the abuse allegation and protect the resident led to a determination of immediate jeopardy. The facility's policy required immediate reporting and investigation of abuse allegations, which was not followed in this case.
Removal Plan
- CNA #2 was suspended pending an investigation.
- An abuse allegation investigation was started which included resident interviews and reporting of the allegation to the appropriate entities.
- Education was provided to all staff on abuse reporting notification and investigation which included education of oncoming staff before contact with residents.
Failure to Provide CPR According to Advance Directive
Penalty
Summary
The facility failed to provide CPR in accordance with a resident's advance directive, resulting in the resident's death shortly after admission. The resident had signed a POLST indicating a full code status, which was also signed by the physician. However, when the resident became unresponsive and lost signs of life, the staff did not initiate CPR. The administrator and the DON both believed the resident was a DNR/DNI based on information from the hospital and were unaware of the updated POLST. The POLST was not found in the disaster recovery binder at the nurses' station, and there was no documentation of the resident's mottling or physician notification prior to the resident's death. Interviews with various staff members revealed a lack of awareness and communication regarding the resident's code status. The LPN who admitted the resident did not recall the resident's code status, and the social worker confirmed that medical records personnel processed the admission paperwork, including the POLST. The physician who signed the POLST was not notified of any concerns until the resident's death. The facility's policies on code blue and advance directives were not followed, leading to the failure to provide CPR as requested by the resident's advance directive.
Removal Plan
- Education to all staff regarding POLST forms and code blue.
- 100% audit of all POLST forms for all current residents.
- Audit of all licensed nurses for verification of up to date CPR.
- A mock Code Blue drill was conducted and would occur on every shift.
Resident Abuse and Neglect by CNAs
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as well as neglect, as evidenced by incidents involving two CNAs. The resident, who had severe cognitive impairment and was dependent on staff for personal care, was left unattended in the bathroom and went unchecked for 13 hours during a CNA's shift. This neglect was captured on audio/video surveillance, and other staff reported concerns about the conditions of residents, such as saturated briefs and beds, and dried feces and urine left on beds. In another incident, the resident's daughter provided video footage showing a CNA verbally and physically abusing the resident. The footage showed the CNA pushing the resident in bed, pulling the resident up by one arm, and using aggressive and threatening body language. The CNA was also observed turning off the resident's call light and refusing to take the resident to the bathroom, leading to the resident expressing fear about calling for help. Interviews revealed that the CNA involved in the physical and verbal abuse had complained about being overwhelmed and needing help. The CNA stated that she had no intention of hurting the resident and was frustrated during the shift. The resident's daughter reported these incidents to the facility, and the resident exhibited new fearful behavior following the incidents.
Removal Plan
- Resident assessment
- CNA suspension
- Facility reported to adult protection agency, state survey agency, and state board of nursing
- Disciplinary action for the perpetrators
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in harm to two residents. Resident #5, who had moderate cognitive impairment and various medical conditions, was injured in an altercation with resident #1, who also had significant cognitive impairment and other health issues. During the incident, resident #1 entered resident #5's room, became agitated, and pushed resident #5, causing them to fall and sustain a fracture. This incident was documented in an incident report and confirmed through a facility investigation. A subsequent incident involved resident #1 entering the room of resident #2, who had significant cognitive impairment and multiple diagnoses. Resident #1 hit resident #2 on the shoulder, causing slight redness. This altercation occurred during a shift change when resident #1 was unsupervised, despite being on 1:1 observation. The facility's investigation substantiated both incidents, indicating a failure to adequately supervise and protect residents from abuse.
Removal Plan
- Implemented a quality assessment process improvement (QAPI) program addressing resident-to-resident abuse.
- Placed resident #1 on increased observation.
- Provided staff training including behavior management and working with residents with behaviors to decrease the risk of aggression towards other residents.
- Placed resident #1 on 1:1 observation.
- Plans made to transfer resident #1 to another facility.
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