Big Horn Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sheridan, Wyoming.
- Location
- 1851 Big Horn Ave, Sheridan, Wyoming 82801
- CMS Provider Number
- 535026
- Inspections on file
- 36
- Latest survey
- May 7, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Big Horn Rehabilitation And Care Center during CMS and state inspections, most recent first.
A facility failed to keep residents’ personal and medical records secure and confidential. Medical record review showed hospice notes were entered directly into the EMR for three residents, and the regional clinical director stated the hospice previously used was given full access to the EMR for all residents. The Resident Rights policy stated residents have a right to secure and confidential personal and medical records.
Failure to Offer Choice of Hospice Provider: The facility did not ensure that 3 residents receiving hospice services were offered a choice of hospice provider. Medical record review showed no evidence that the residents were given provider choice, and an RCD confirmed that prior to the operator transition, hospice residents were not given a choice. The facility's Resident Rights policy states residents have the right to choose health care and providers of health care services.
Failure to Assess and Document Changes in Condition: A resident with repeated falls, hypoxia, lethargy, and later hospital transfers had multiple episodes where assessments, vital signs, or follow-up documentation were missing or delayed. Another resident with COPD and impaired gas exchange was observed in respiratory distress without oxygen and was later transferred for respiratory failure, with no transfer documentation on the progress notes. A third resident with dementia and a history of falls had incomplete post-fall assessments and was later sent to the hospital after additional falls and pain. A fourth resident with a Foley catheter had cloudy, low, and absent output, pain, and family requests for transfer; the catheter was later found to have caused traumatic injury and hematuria.
Opened medications in two medication fridges were found without required opened-on or discard dates. An Ozempic pen in one fridge and an opened Tubersol vial plus an opened Ativan oral solution in another fridge were all in use but unlabeled, and staff confirmed the missing dates. The DON stated she expected in-use multi-dose vials to have an opened-on or discard-by date, and manufacturer guidance reviewed for these medications specified discard timelines after opening.
A facility failed to ensure hospice services met professional standards for 3 sampled residents. Medical record review showed each resident was receiving hospice services, but none of the records contained a physician order for hospice referral or eval. An RCD confirmed that residents placed on hospice did not receive a physician order for eval and that the hospice used at the time had access to all resident medical records.
Infection control was not maintained during meal service and resident care. A CNA touched hair, clothing, and other surfaces while handling meal tickets, food, and drink cups without hand hygiene, including placing chips on a resident’s burger and touching cup rims. Staff also left visibly soiled linens in place for a resident with bowel incontinence, and oxygen cannulas/tubing for multiple residents were found on the floor or unlabeled, with one cannula picked up from the floor and placed on a resident.
A facility failed to ensure pneumococcal immunization status was assessed for 5 of 5 sampled residents. Medical record review showed no evidence that PCV had been assessed or offered, and the IP confirmed there was no documentation of pneumococcal vaccination status. The facility reported its immunization process tracked vaccines on admission and documented annual COVID and influenza vaccines, but the pneumococcal audit had been delayed because records could not be accessed.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
Failure to Investigate Allegation of Verbal Abuse: A volunteer reported that an activities staff member yelled at a resident during bingo and then yelled at the volunteer when she intervened. Interviews with the resident and volunteer confirmed the staff member spoke rudely and loudly to the resident, and the regional clinical director confirmed there was no evidence the verbal abuse allegation was reported or investigated.
Failure to Allow Return After Hospital Transfer: A resident was transferred to the ER for altered mental status and increased confusion, but the facility did not provide a transfer/discharge notice and did not allow the resident to return after the acute hospitalization. The DON stated the decision not to permit return was financial, while the business office manager believed it was due to insufficient staffing. The facility policy stated residents transferred to acute care will be permitted to return upon discharge, and not permitting return constitutes a discharge.
The facility failed to provide written transfer/discharge notices for three residents who were sent to the hospital, and for one resident it also failed to provide written bed-hold policy information. In one case, an LPN said she did not notify the guardian because she was the only nurse on the unit and did not have time, and there was no evidence that the Ombudsman was notified of the transfers.
Failure to provide individualized activities for a resident with dementia. The resident's representative said the resident had not received activities and needed to stay busy, while survey observations showed the resident wandering in the halls and sitting in the lobby without participating in facility activities. The DON reported there was no record of activity participation, and an activity staff member said she only talked with the resident occasionally and was the only activity staff member, so she did not have time.
A resident with schizophrenia, anxiety, and PTSD reported a preference for female staff only for bathing and personal care due to past sexual assault trauma, but the care plan did not identify this preference or PTSD triggers. The resident said staff had to be reminded weekly, and a CNA confirmed the preference for female staff because of past trauma.
Activities Program Not Directed by a Qualified Professional: A resident reported the facility had been without an activity director for about a month. The ADM and regional clinical director confirmed there was no qualified activity professional in place, the newly hired director was not yet qualified, and OT would oversee the program until qualification was met. The regional clinical director later confirmed the activity program was not being overseen by a qualified person after the prior activity director left.
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.
Surveyors found that resident rooms on multiple units lacked basic linens such as washcloths, bath towels, and hand towels, despite clean linens being available in supply storage and expectations from the DON that staff keep rooms stocked. A resident representative reported that a resident’s room in a secure unit had no bathroom door throughout the stay, and later observation showed the bathroom still lacked a door. In another room, broken tiles under a toilet riser were dirty and emitted a urine odor; the resident reported notifying maintenance months earlier and being told repairs were delayed for remodeling. Housekeeping staff stated they would notify maintenance and supervisors of needed repairs, and the maintenance director acknowledged awareness of the broken tiles and that both tile repair and the bathroom door replacement were pending.
The facility failed to support the rights of families to organize and participate in a family council by canceling a scheduled monthly meeting and not providing a private meeting space. The family council president reported that a posted notice announced the cancellation of the monthly meeting and directed questions to social services, and also reported being told by the former activity director that there would be no meeting and possibly no subsequent meeting because the council members were considered trouble makers. Review of family council records confirmed that no meeting occurred during the affected month, despite meetings typically being held during the third or fourth week of each month.
A resident with moderate cognitive impairment, dementia diagnoses, depressive symptoms, and on antipsychotic medication repeatedly stated an intent to leave and became angry when told by their POA and family they could not go home. Throughout the day, the resident declined evening medications, talked about leaving, packed two bags of clothing, and walked toward the lobby stating they were going home, yet the medical record showed no evidence that additional supervision was implemented in response to these behaviors. The facility’s elopement policy required adequate supervision and monitoring for residents at risk, but the DON later reported uncertainty about whether the resident had a wanderguard, and the resident ultimately eloped and was later found off-site.
The facility failed to ensure social services were provided by a qualified full-time social worker in a building with more than 120 beds. The SSD hired for the role held a bachelor’s degree in criminal justice rather than in a qualifying social work field and relied only on informal, as-needed consultation with a social worker at another facility, without regular supervision. The NHA acknowledged he had assumed the SSD had appropriate consultation and confirmed there was no facility policy defining the required qualifications for the social worker position.
Two residents experienced actual harm due to the facility's failure to follow professional standards, including not calling EMS after a fall with neurological symptoms and delaying hospital transfer for a resident with declining condition and suspected UTI. Staff decisions were influenced by cost and convenience, and required provider notifications were not made in a timely manner.
A resident with multiple medical conditions was found on the floor after a fall, exhibiting symptoms such as inability to move limbs, head injury, and nausea. Staff, including an LPN and the DON, lifted the resident into a wheelchair and transported them to the ER in the facility van instead of calling 911, citing cost and convenience. The nurse practitioner was not notified, and facility policy requiring physician notification and emergency services activation was not followed, resulting in actual harm to the resident.
The facility did not consistently provide showers according to resident preferences and care plans, with several residents receiving fewer showers than scheduled and lacking documentation of offers or refusals. Staff interviews cited inadequate CNA staffing as a reason for missed showers, and the DON acknowledged that staff shortages and resident preferences sometimes led to missed bathing opportunities.
The facility did not provide enough nursing staff on one care unit, leading to multiple residents missing scheduled showers or not being offered bathing as required by their care plans. Residents reported infrequent showers, and CNAs confirmed that low staffing levels made it difficult to complete bathing tasks, especially at night, as they had to prioritize other care needs. The DON acknowledged staffing challenges and the impact on resident care.
A resident with moderate cognitive impairment and multiple comorbidities fell from a mechanical lift during transfer due to a wet brief, despite proper sling placement. Staff failed to document the incident, update the care plan, or notify the nurse practitioner, and required post-fall procedures were not followed according to facility policy.
The facility did not maintain accurate and complete medical records for two residents who experienced falls. In both cases, required documentation of the incidents, updates to care plans, and notifications to the nurse practitioner were missing or incomplete, despite facility policy mandating these actions after a fall.
The facility did not report the results of multiple abuse investigations to the State Agency within the required 5 working days. Incidents included verbal abuse between a resident and staff, abuse between two residents, and abuse by a resident toward an LPN. Investigations were not completed or submitted, and the investigations binder was reported missing. Staff interviews confirmed the required reports were not made as per facility policy.
The facility did not complete or submit required investigations for multiple abuse allegations involving residents and staff, despite initial incident reports being filed. Leadership interviews confirmed missing documentation and failure to follow policy for reporting and investigating abuse cases.
A resident with multiple cardiac conditions experienced acute symptoms and was transferred to the ED without prior notification to their representative, contrary to facility policy. The representative only learned of the transfer upon arriving at the facility, and interviews confirmed that no notification or paperwork was provided.
A resident with severe cognitive impairment and multiple diagnoses was subjected to abuse when a CNA recorded and posted a demeaning video of the resident in the bathroom, highlighting the resident's incontinence. The incident was not reviewed by the QAPI committee as required by facility policy, and no further systemic action was taken beyond staff education and resident monitoring.
A resident with multiple cardiac conditions and a colostomy, who was previously able to walk independently, experienced a decline in mobility after being discharged from therapy and not receiving restorative services. Staff interviews revealed that the restorative aide was reassigned due to staffing shortages, and the restorative program was not operational, resulting in the resident relying on a wheelchair for mobility.
The facility failed to report resident-to-resident altercations within the required timeframe, as per their policy. In three separate incidents, altercations resulted in minor injuries, but the state agency was notified days later, contrary to the policy requiring immediate reporting within two hours. The facility administrator confirmed the delay in reporting.
A facility failed to provide sufficient nursing staff on the Courtyard unit, resulting in a significant medication administration deficiency. On a specific day, no nurse or MA-C was scheduled for the shift, leading to missed medications for residents with conditions like depression, hypertension, and dementia. The former DON, who was supposed to cover, admitted to being the only nurse and was unable to administer medications. This resulted in residents exhibiting distressing behaviors typical of missed medications.
The facility failed to accurately document medication administration for several residents, resulting in significant medication errors. On a particular day, the former DON signed off on medications that were not administered, as confirmed by staff interviews. The absence of a staff member to pass medications on the Courtyard unit led to residents exhibiting behaviors consistent with missed doses. The former DON admitted to being the only nurse present and unable to manage the situation, resulting in a serious medication error.
The facility failed to maintain acceptable nutritional status for two residents, resulting in significant weight loss. One resident lost 18.71% of their body weight, while another lost 11.65%. Meal intake records showed numerous unrecorded meals and low consumption rates. Staff interviews revealed a lack of personnel to assist residents during meals, and the facility's policy on meal supervision was not adequately followed.
The facility failed to ensure residents' privacy and timely delivery of mail. Residents reported that mail was locked up, not delivered on Saturdays, and sometimes opened by the business office. The activities director confirmed sorting mail and taking it to the business office, where the new manager opened it to determine its destination. An observation showed a stack of residents' mail on the business office desk.
The facility failed to provide adequate personal hygiene services, specifically showers, for three residents due to staffing shortages. A resident requiring substantial assistance with bathing reported not receiving showers routinely, with records showing multiple extended periods without a shower. Another resident, cognitively intact, experienced significant gaps between showers, while a third resident, with moderate cognitive impairment, often missed scheduled showers. Interviews confirmed insufficient staffing levels impacted the ability to provide necessary care.
The facility failed to provide adequate nursing staff, affecting resident care across three units. Observations and interviews revealed long wait times for assistance, missed showers, and unmet care needs. Staffing schedules showed multiple days of insufficient staffing, and the administration acknowledged the issue, citing staff turnover and departures.
The facility failed to label insulin pens appropriately in two medication carts, despite having yellow stickers available for labeling. Observations showed opened and undated insulin pens, and interviews with staff confirmed the requirement for labeling with open and expiration dates. The facility's policy mandated labeling upon opening, but this was not followed.
A facility failed to honor a resident's advance directive choice, resulting in a discrepancy between the resident's documented code status and their expressed wishes. The EHR indicated a 'Full Code' status, while a WyoPOLST form signed by the resident showed a preference for 'DNR/Do Not Attempt Resuscitation.' The DON confirmed the resident's choice was not accurately reflected in the EHR.
The facility failed to perform accurate PASARR screenings for two residents with mental disorders. One resident with depression and bipolar disease had a PASARR Level I assessment that incorrectly showed no mental illness, missing a necessary Level II evaluation. Another resident with similar diagnoses had inconsistent PASARR assessments, initially indicating a major mental illness but later showing no evidence of it. These issues were linked to the social services director's duties, who was terminated.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained secure and confidential. Medical record review showed that resident #26 received hospice services beginning on 1/2/26, resident #83 received hospice services beginning on 1/21/26, and resident #84 received hospice services beginning on 2/5/26, and the hospice provided documented notes directly into the electronic medical record system. During interview on 5/6/26 at 12:44 PM, the regional clinical director stated the only hospice used prior to a change in operator was given full access to the electronic medical record for all residents. Review of the facility’s Resident Rights policy stated residents have a right to privacy and confidentiality of personal and medical records and the right to secure and confidential records.
Failure to Offer Choice of Hospice Provider
Penalty
Summary
The facility failed to ensure residents' right to choose their health care providers for 3 of 12 sampled residents reviewed for hospice services. Resident #26 began receiving hospice services on 1/2/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but the medical record review showed no evidence that any of these residents were offered a choice in hospice provider. During an interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that prior to the operator transition, residents on hospice were not given a choice for hospice provider. The facility's Resident Rights policy, last revised on 6/10/25, states that the resident has the right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care.
Failure to Assess and Document Changes in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for four residents who experienced changes in condition. For resident #1, the record showed multiple episodes where the resident was found after falls, had low oxygen saturations, became lethargic, or was unresponsive, yet there was no evidence of timely assessments, vital signs, or follow-up documentation at several of those events. The record also showed a late entry note for a 3/5/26 incident was added 62 days after the event. The resident was later transferred to the hospital for respiratory failure, pneumonia, acute heart failure, dry gangrene, hyponatremia, metabolic encephalopathy, pulmonary edema, critical electrolyte abnormalities, atrial fibrillation with RVR, and acute kidney injury. For resident #69, the resident had diagnoses including chronic myeloid leukemia, CAD, seizure disorder, traumatic brain injury, and COPD, and the care plan addressed impaired gas exchange. On 5/4/26, the resident was observed sitting on the edge of the bed with a respiratory rate of 30-40 breaths per minute, grey pallor, and no oxygen in place. The resident was later sent to the hospital for respiratory failure, but the progress notes for the transfer did not show documentation on 5/5/26. A later facility note stated the resident had been found with oxygen saturation of 60% on 4 lpm NC, difficulty breathing, and lethargy, and the LPN reported she had been asked to come in on her day off to document the assessment and transfer. For resident #81, who had severe cognitive impairment, dementia, COPD, atrial fibrillation, CAD, diabetes, and a history of falls, the record showed repeated falls and incomplete assessments. After a fall on 4/20/26, the assessment section was left blank. Another note dated 4/23/26 documented pain, confusion, and unsteadiness but stated there were no safety risks. After a fall on 4/25/26, staff documented vital signs and a normal assessment but did not know whether the resident hit his/her head, and there was no evidence of follow-up assessments. After a fall on 4/30/26, the resident was found on the floor with pain, and the interdisciplinary review identified impaired cognition, weakness, and self-transfers as the root cause, with a new skin tear noted. The resident's representative reported the resident was in significant pain, not at baseline, disheveled, saturated with urine, had neck swelling, and was missing a pain patch, and stated no vital signs or assessment had been done before the resident was sent to the hospital. For resident #6, who had moderate cognitive impairment, cancer, CAD, heart failure, renal disease, dementia, and an indwelling catheter, the care plan identified UTI risk related to the Foley catheter. After a recent hospitalization for sepsis related to UTI/prostate cancer, the record showed thick cloudy catheter output, complaints of pain, and periods of no catheter output. The resident's family repeatedly requested hospital transfer, and the catheter was changed after the resident had no output since the prior shift; the catheter then drained but had bloody urine. The resident later had cloudy grayish-yellow urine, was not getting up for breakfast, and was transferred to the ED. The ER report stated the Foley had caused traumatic injury and hematuria because the balloon was inflated in the prostatic urethra, and the resident also had AKI with creatinine elevated above baseline. The DON stated she expected transfer documentation to include resident condition, vital signs, notifications, and immediate or within-24-hour documentation, and confirmed that only vital signs were completed and ongoing assessment was not completed as expected.
Medication Labeling Deficiency in Two Medication Fridges
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles because opened medications in two medication refrigerators did not have an opened-on or discard date. During observation in the Rock Creek medication fridge, an Ozempic 8 mg/3 ml pen was found with no opened-on or discard date. MA-C #1 confirmed the Ozempic pen had been opened and used the day before and that no date had been written on it. In the secure unit fridge, an opened Tubersol vial and an opened Ativan oral solution 2 mg/ml were observed without opened-on or discard dates. LPN #2 confirmed both medications were in use and that neither had the required dates. The DON stated she expected an opened-on or discard-by date to be written on in-use multi-dose vials. Manufacturer instructions reviewed for Ozempic, oral liquid Lorazepam, and Tubersol specified time limits for use after opening, and the facility policy required multi-use vials to include the date initially opened or accessed.
Missing Physician Orders for Hospice Referrals
Penalty
Summary
The facility failed to ensure hospice services met professional standards for 3 of 12 sampled residents. Medical record review showed that resident #7 began receiving hospice services on 3/31/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but none of the three records contained evidence of a physician order for a hospice referral or evaluation. During interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that residents placed on hospice did not receive a physician order for evaluation and that the hospice used at that time was given access to the medical record for all residents.
Infection Control Lapses During Dining, Linen Care, and Oxygen Equipment Handling
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for resident care and meal service. During dining room observation, a CNA touched his hair, handled resident meal tickets, and repeatedly handled resident food and drink items with exposed hands without performing hand hygiene between tasks. The CNA placed a bag of chips on top of a resident’s hamburger, touched the top bun to apply jelly, handled drink cups by the rims, and continued passing trays after touching his pants, hair, and other surfaces. The infection preventionist and DON confirmed staff were expected to perform hand hygiene after touching hair, skin, or clothing and that the CNA should not have touched resident meal items without hand hygiene. The facility also failed to manage soiled linens and oxygen equipment for residents with visible contamination or tubing on the floor. One resident had linens visibly soiled with bowel movement incontinence, yet the blanket was pulled over the sheets, the soiled linen remained visible during later observations, the resident lay on top of an oxygen cannula on the soiled sheets, and housekeeping picked up the cannula from the floor and placed it on the resident. Two other residents had nasal cannulas or oxygen tubing on the floor or unlabeled, including tubing dated 4/19/26 and tubing labeled 5/3/26 that remained on the floor during repeated observations. The IP confirmed oxygen tubing should be changed and labeled weekly and as needed or when visibly soiled, that cannulas found on the floor should not be used on residents, and that soiled linens should be changed immediately.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure residents were immunized for pneumococcal disease for 5 of 5 sampled residents (#66, #69, #1, #33, and #4) reviewed for current vaccination status. Medical record review showed no pneumococcal conjugate vaccine had been assessed or offered for these residents. The infection preventionist confirmed there was no evidence of pneumococcal vaccination status, and also stated the facility’s immunization process assessed and tracked vaccines on admission, with annual COVID and influenza vaccines offered and documented, but that the pneumococcal vaccine audit had been delayed because records could not be accessed. CDC guidance reviewed by surveyors indicated that adults age 19 years or older with unknown or no prior PCV history should receive PCV15, PCV20, or PCV21.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for resident #55. A complaint/grievance form documented that a volunteer reported activities staff member #1 yelled at resident #55 during bingo after the resident called out bingo, and the volunteer stated the staff member continued yelling at the resident and then yelled at the volunteer when she intervened. The grievance also noted that two residents reported the activities staff member yelled at them all the time and spoke to them the same way during bingo. Interviews confirmed the incident involved rude and loud comments by the activities staff member toward resident #55 during bingo, including telling the resident to stop interrupting and making a smart-ass remark. Resident #55 stated the interaction upset him/her and that the staff member was later terminated. A volunteer corroborated hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was investigated.
Failure to Allow Return After Hospital Transfer
Penalty
Summary
The facility failed to ensure resident #82 was allowed to return after an acute hospitalization. A progress note dated 3/11/26 at 8:33 PM documented that the resident was transferred to the hospital emergency room for altered mental status and increased confusion. The medical record showed no evidence that a transfer/discharge notice was provided at the time of transfer. A discharge MDS assessment showed the resident’s return to the facility was anticipated and that the discharge was unplanned, with a discharge status of Short-Term General Hospital (acute hospital, IPPS). Interviews confirmed the resident did not return to the facility after the hospital transfer. The DON stated on 5/7/26 at 9:45 AM that the decision not to allow the resident to return was financial, and also confirmed that no discharge notice was provided after transfer and that the facility did not assist in finding alternate placement. The business office manager stated on 5/7/26 at 10:54 AM that the resident was not allowed to return following the hospital transfer, although he believed the reason was insufficient staffing. The facility policy stated that residents transferred to acute care will be permitted to return upon discharge and that not permitting a resident to return following hospitalization constitutes a discharge.
Failure to Provide Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge before facility-initiated hospital transfers for 3 of 6 sampled residents (#6, #69, and #77). Medical record review showed resident #6 was transferred to the hospital and there was no evidence that a written transfer/discharge notice was issued to the resident or resident representative. There was also no evidence that a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. The Regional Clinical Director confirmed there was no evidence the notice had been provided. Resident #69 was transferred to the hospital and the record showed no evidence that the facility issued a written transfer/discharge notice to the resident or the resident's guardian. An LPN stated she did not notify the guardian because she was the only nurse on the unit and did not have time, and she reported to the next shift that the guardian had not been notified. The guardian confirmed she had not been notified of the transfer. Resident #77 was transferred to the hospital and the record showed no evidence that the facility issued a written transfer/discharge notice or written information on the bed-hold policy to the resident or resident representative, and there was no evidence that the Ombudsman was notified of the transfer. The Regional Clinical Director confirmed there was no evidence the bed-hold and transfer/discharge notices were provided.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to ensure individual activities of preference were provided to a resident with Alzheimer's disease who was identified in the care plan as being at risk for depression and impaired social interaction and who was expected to participate in social situations and activities of choice. The resident's representative stated the resident had not received activities at the facility and needed to stay busy because of dementia, and reported that attempts to speak with activity staff about appropriate activities were unsuccessful because staff were always on their way somewhere else. Survey observations showed the resident wandering in the halls and sitting in the front lobby, and the resident was not observed participating in facility activities. The DON stated there was no record of activity participation for the resident, and an activity staff member stated she only sat and talked with the resident once in a while and was the only activity staff member, so she did not have time. The facility policy also stated that special considerations would be made for developing meaningful activities for residents with dementia and/or special needs.
Failure to Honor Resident Preference for Female Staff During Personal Care
Penalty
Summary
The facility failed to ensure that one resident with a BIMS score of 13, diagnoses of schizophrenia, anxiety, and PTSD, received care that accounted for personal preferences intended to reduce triggers related to past trauma. The resident stated during interview that due to PTSD from a prior sexual assault, the resident requested that men not bathe him/her, and reported having to remind staff weekly of this preference. The care plan dated 1/23/26 did not identify the resident's preference for female staff only for personalized care, ADLs, and bathing, and did not identify PTSD triggers or the preference for only female staff to assist with bathing. A CNA confirmed that the resident preferred female staff because of past trauma.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. Resident #55 stated on 5/5/26 that the facility had not had an activity director for about a month. On 5/6/26, the administrator and regional clinical director confirmed the facility did not have a qualified activity professional at that time, and they stated a new activity professional had been hired even though the new director who would be starting was not qualified. They also stated the program would be overseen by occupational therapy until qualification was met. On 5/7/26, the regional clinical director confirmed the activity program was not being overseen by a qualified person and that the previous activity director left on 3/18/26.
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.
Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment on multiple units. Observations over two days showed that resident rooms on three of four units lacked basic linens such as washcloths, bath towels, and hand towels. A resident representative reported that there was never any linen in one resident’s room to assist with bathing during the resident’s approximately six‑week stay. The DON stated that staff were expected to stock resident rooms with washcloths and clean linen as required, and the director of housekeeping and an RN confirmed that clean linens were available in the clean supply storage and should be supplied from there when needed. The same resident representative also reported that the resident’s bathroom had no door in place during the entire stay in a secure unit room, and subsequent observation months later showed that the room remained without a bathroom door. Surveyors also found environmental safety and cleanliness issues related to maintenance. In one room, broken tiles under both toilet riser legs appeared dirty and had a urine odor. The resident in that room stated they had reported the broken tile to maintenance over two months earlier and were told the repair was being delayed due to planned remodeling. Housekeeping staff reported that they would notify maintenance and supervisory staff when items, including doors, required repair. The maintenance director confirmed awareness of the broken tiles and stated that repair was pending a planned remodel, and further stated that the bathroom door had been on order for a couple of months.
Failure to Provide Meeting Space and Support for Family Council
Penalty
Summary
The facility failed to honor residents’ and families’ rights to organize and participate in family council groups by not providing and supporting a private meeting space for the family council for one month in 2025. According to the family council president, the facility canceled the family council meeting for March 2025 and did not provide a meeting space, as reflected by a sign posted on the community board stating that the March family council meeting was canceled and directing individuals to contact social services with questions. The family council president further reported being told by the former activity director that there would not be a meeting in March and that there might not be one in April because the council members were considered “trouble makers.” Review of family council meeting records confirmed that no meeting occurred in March 2025 and that meetings were typically held during the third or fourth week of each month.
Failure to Provide Adequate Supervision to Prevent Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with cognitive impairment and behavioral indicators of wanting to leave. The resident had a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, and cancer. The resident’s mood interview showed frequent feelings of being down or depressed, and the resident was receiving an antipsychotic medication. An elopement evaluation completed earlier showed a score of 0, and there was no indication in the record that this assessment was updated in response to later behaviors. On one day, multiple progress notes documented that the resident repeatedly expressed a desire and intent to leave the facility. The resident told the social services director (SSD) that they were going to leave, and the SSD informed the Ombudsman, DFS, and attempted to contact the resident’s POA and family. Subsequent notes showed the resident became angry after being told by the POA that they could not take the resident home, continued to state they were leaving, declined evening medications, and ranted about leaving and having a family member pick them up. The nurse encouraged the resident not to pull out their Foley catheter, and the DON and SSD spoke with the resident. The resident then left their room with two bags of clothing, walked toward the lobby, and stated they were going home with family. Despite these escalating statements and actions indicating intent to leave, review of the medical record showed no evidence that additional supervision was implemented after the resident voiced the desire to leave. The facility’s elopement policy required that residents at risk for elopement receive adequate supervision and that charge nurses and unit managers monitor implementation of interventions and document accordingly. The DON later reported being unsure whether the resident had a wanderguard. The resident ultimately left the facility and was later located off-site, confirming that the resident had eloped after repeatedly expressing the intention to do so without the facility having implemented additional supervision measures in response to those behaviors.
Unqualified Social Services Director Without Defined Qualification Policy
Penalty
Summary
The facility failed to ensure that social services were provided by a qualified full-time social worker in a facility with more than 120 beds. The Social Services Director (SSD), interviewed on 2/4/26, reported she began working in the role in October 2025 and confirmed that her bachelor’s degree was in criminal justice, not in a qualifying social work field. She stated that when she had questions, she reached out informally to a social worker at another facility, but she did not have any regular scheduled meetings or formal supervision with that individual. In a separate interview on 2/5/26, the Nursing Home Administrator (NHA) stated he assumed the SSD had someone she consulted with from her hire date to the present, but he did not verify this. He further acknowledged that the facility did not have a policy outlining the required qualifications for the social worker position, contributing to the hiring of an SSD who did not meet the regulatory educational requirements.
Failure to Provide Timely Emergency Response and Clinical Notification
Penalty
Summary
The facility failed to ensure that services provided met professional standards for two residents, resulting in actual harm. In the first case, a cognitively intact resident with multiple diagnoses, including cancer and diabetes, was found on the floor after a fall, unable to move their arms or legs, and with a small amount of blood behind the head. Despite these significant symptoms, including complaints of nausea, numbness, and inability to maintain upper body balance, staff did not call emergency medical services. Instead, the resident was lifted by several staff members into a wheelchair and transported to the emergency room in the facility van, accompanied by a CNA and the activities director. Staff interviews revealed that the decision not to call 911 was based on cost and perceived convenience, even though the resident exhibited signs of a possible spinal injury and head trauma. The nurse practitioner was not notified of the fall or the need for hospital transport at the time of the incident. In the second case, another resident with complex medical needs, including malnutrition, fractures, chronic respiratory failure, and a urinary catheter, experienced a significant decline in condition. The care plan indicated the resident required extensive assistance for mobility and toileting, and monitoring for signs of urinary tract infection (UTI). Despite orders for laboratory tests and a urinalysis, the urine sample was not obtained as directed. Over several days, nursing staff documented decreased urinary output, increased drowsiness, and changes in mental status. When a nurse reported these changes and recommended hospital transfer, she was instructed by the staff development coordinator to wait for the night nurse's opinion, delaying the transfer. The nurse was also told not to contact the provider, and her ability to make clinical decisions was limited by management. The resident was eventually transferred to the hospital after further decline, but the nurse practitioner was not notified of the change in condition prior to transfer, and the urinalysis was not completed until arrival at the hospital. Facility policies required prompt notification of physicians and families following significant changes in resident condition, including falls and clinical deterioration. However, in both cases, there was a failure to follow these protocols, resulting in delayed medical evaluation and intervention. Staff interviews confirmed that decisions regarding emergency transfers were influenced by non-clinical factors such as cost and convenience, and that communication with providers was inadequate during critical events.
Failure to Provide Appropriate Emergency Response After Resident Fall
Penalty
Summary
A resident with a history of cancer, diabetes mellitus, hypertension, and arthritis, and who was cognitively intact, experienced a fall in their room and was found on the floor with a small amount of blood behind the head, unable to move their arms or legs. Multiple staff, including a resident assistant, LPNs, CNAs, and the activities director, observed that the resident could not sit up or maintain upper body balance and had symptoms such as nausea, vomiting, and abnormal limb movements. Despite these significant symptoms and the presence of a head injury, staff, under the direction of the former DON, lifted the resident into a wheelchair and transported them to the ER in the facility van, rather than calling emergency medical services. The decision to use the facility van was based on the perceived expense and speed compared to calling an ambulance. The facility failed to notify the nurse practitioner of the fall or the need for hospital transport, contrary to facility policy, and did not follow the established protocol to call 911 for residents requiring a higher level of care. The facility's Fall Prevention Policy required physician and family notification after a fall, which was not followed in this case. The actions and inactions of the staff resulted in actual harm to the resident, who was later diagnosed with cervical spine fractures.
Failure to Provide Showers per Resident Preference and Schedule
Penalty
Summary
The facility failed to ensure that bathing was performed according to residents' preferences and care plans for three out of four sampled residents. Documentation showed that showers were not consistently offered or provided as scheduled, and there was no evidence that alternative bathing times were offered, accepted, or refused in several instances. Residents reported receiving fewer showers than scheduled, with one resident stating they only received a shower every two weeks and would prefer more frequent bathing if staffing allowed. Another resident, who required assistance from two staff members, reported only receiving one shower per week instead of the scheduled two. A third resident, who preferred three showers per week due to frequent diarrhea and requested a female caregiver, did not receive showers according to their stated preference and reported not having a shower for a week. Staff interviews revealed that showers were often missed due to inadequate staffing, particularly during night shifts when only two CNAs were available, making it difficult to provide both necessary care and showers. Staff indicated that on some days, they could only provide one shower due to prioritizing call lights over bathing. The DON confirmed that showers were expected to be provided on scheduled days and rescheduled if missed, but acknowledged that staff preferences and shortages sometimes led to missed showers. Review of facility policy indicated that showers should be provided per resident request or facility schedule, based on resident safety.
Insufficient Nursing Staff Resulting in Missed Resident Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on one of its care units, resulting in missed and inconsistent bathing care for multiple residents. Documentation showed that residents who required assistance with showers did not consistently receive them as scheduled, with records lacking evidence that showers were offered, accepted, or refused on several occasions. Interviews with residents confirmed that showers were not provided according to their care plans or preferences, with some residents receiving showers only once every two weeks or less frequently than their care plans specified. One resident, who required assistance from two staff members, went 22 days without documented bathing after a scheduled shower, and another resident with frequent diarrhea did not receive the three showers per week as preferred. Staff interviews revealed that insufficient CNA staffing, particularly during night shifts, prevented the completion of scheduled showers, as staff had to prioritize other resident care needs such as answering call lights. CNAs reported that on some days, they could only provide one shower due to low staffing levels, despite the expectation to complete more. The DON acknowledged ongoing efforts to stabilize the staff schedule but confirmed that missed showers were sometimes due to staff shortages and resident staff preferences, which led to missed opportunities for care.
Failure to Prevent and Document Resident Fall During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment, diabetes, congestive heart failure, and morbid obesity. The resident, who was dependent for transfers and self-care and incontinent, was identified as being at risk for falls. During a mechanical lift transfer from wheelchair to bed, the resident slipped through the sling and fell to the floor due to a wet brief, despite the sling being placed appropriately. Multiple staff interviews confirmed the fall, and the resident's representative was notified by phone. However, there was no incident report available for the representative, and the resident was later discharged to another facility. Further review revealed significant lapses in documentation and follow-up. The nurse on duty after the fall was unaware of the incident until contacted by the resident's representative, and her subsequent documentation was deleted. The DON confirmed that required documentation, including risk management and progress notes, could not be found in the medical record, and there was no follow-up with risk management. The nurse practitioner was not notified of the fall, and the resident's care plan was not updated post-incident. Facility policy required assessment, post-fall assessment, incident reporting, physician and family notification, care plan review, documentation, and witness statements, none of which were fully completed in this case.
Failure to Maintain Accurate Medical Records and Post-Fall Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents who experienced falls. For one resident with moderate cognitive impairment and multiple comorbidities, there was no documentation in the medical record regarding a fall that occurred during a mechanical lift transfer, despite staff interviews confirming the incident. The resident's representative was informed of the fall, but was told that an incident report could not be found. Nursing staff reported that documentation related to the fall, including risk management and progress notes, was either missing or had been deleted from the record. Additionally, the care plan was not updated following the fall, and the nurse practitioner was not notified of the incident. For another resident, who was cognitively intact and had several chronic conditions, the facility's incident report indicated a fall resulting in cervical spine fractures and subsequent transport to the emergency room. However, the nurse practitioner reported not being notified of the fall or the need for hospital transport, despite facility documentation stating otherwise. Review of facility policy showed that required actions after a fall, such as assessment, documentation, incident reporting, and care plan review, were not consistently followed for these residents.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of abuse investigations within 5 working days to the State Agency for four residents who were involved in allegations of abuse, neglect, or theft. In one case, an allegation of verbal abuse between a resident and a staff member was reported, but no investigation was completed or submitted to the State Agency as of over two months later. In another instance, an incident of abuse between two residents was reported, but again, no investigation was completed or reported. A third case involved an incident of abuse by a resident toward an LPN, with no investigation completed or reported within the required timeframe. Interviews with facility staff revealed that the investigations were not present in the facility, and the reportable investigations binder had gone missing. The administration had contacted the police regarding the missing binder. The DON confirmed that investigations should have been submitted by the former SSD but were not, and also stated that the DON did not have access to submit investigations. Review of facility policy confirmed the requirement to report investigation results within 5 working days, which was not followed in these cases.
Failure to Complete and Report Abuse Investigations
Penalty
Summary
The facility failed to ensure thorough investigations were completed and the results reported to the State Agency for four out of eleven sampled residents who were involved in allegations of abuse. In multiple incidents, including verbal abuse between a resident and a staff member, abuse between two residents, and abuse by a resident toward an LPN, the facility did not complete or submit investigations as required. Initial incident reports were sent to the appropriate agency, but no follow-up investigations or results were provided by the facility as of the survey date. Interviews with facility leadership revealed that the investigations were missing, and the reportable investigations binder could not be located within the facility. The administrator and regional nurse confirmed the absence of the required documentation, and the DON stated that investigations should have been submitted by the former SSD but were not. The facility's policy required timely reporting and investigation of abuse allegations, but these procedures were not followed in the cited cases.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition and subsequent transfer to the emergency department (ED). The resident, who had intact cognition and diagnoses including coronary artery disease, heart failure, and hypertension, experienced acute symptoms such as diaphoresis, pallor, chest pain, coughing with bloody sputum, wheezing, shortness of breath, and weakness. The physician on call was notified and recommended transfer to the ED. The resident was transferred by wheelchair once a driver became available. Despite facility policy requiring notification of the resident's representative in the event of a significant change or transfer, the representative was not informed prior to the transfer. The transfer notice was not signed by the resident, and the representative only learned of the transfer upon arriving at the facility to visit. Interviews with both the representative and the DON confirmed that no phone call or paperwork regarding the transfer was provided to the representative.
Failure to Prevent and Address Staff Abuse of Resident with Severe Cognitive Impairment
Penalty
Summary
A staff member failed to protect a resident with severe cognitive impairment from abuse. The resident, who had a BIMS score of 3/15 indicating severely impaired cognition and diagnoses including non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression, was dependent on staff for toileting hygiene and required assistance for toilet transfers. The incident involved a certified nursing assistant (CNA) who recorded and posted a video on social media from the resident's bathroom. In the video, the resident could be heard asking to be let out, while the CNA repeatedly referenced the resident's incontinence in a demeaning manner. The CNA later confirmed the details of the incident and did not recognize the wrongdoing. The facility's investigation revealed that the incident was not reviewed by the Quality Assurance and Performance Improvement (QAPI) committee, despite policy requirements for such cases to be analyzed for root causes and systemic risk factors. The policy also identified demeaning or humiliating videos of residents as possible indicators of abuse, regardless of consent or cognitive status. The Director of Nursing confirmed that, aside from staff education and monitoring the resident, no further action was taken to ensure prevention of similar incidents, and the required QAPI review did not occur.
Failure to Provide Restorative Services Resulting in Decreased Mobility
Penalty
Summary
A deficiency was identified when a resident with a history of coronary artery disease, heart failure, hypertension, and a colostomy, who was cognitively intact and previously able to walk 150 feet independently, experienced a decline in mobility. The resident was initially able to walk with a walker upon admission and was discharged from therapy in March. After therapy discharge, the resident did not receive restorative services, and staff interviews confirmed that the resident's mobility decreased to the point where all mobility was completed with a wheelchair and the resident had not walked since September. The lack of restorative services was attributed to staffing issues, as the restorative aide was reassigned to floor duties, and the restorative program was not operational due to the absence of necessary handbooks. Additionally, the resident's representative reported that therapy was only available privately until Medicaid coverage began, and the resident did not receive restorative services during this period. The physical therapy screening log indicated that a new screen was scheduled but had not yet been completed at the time of the survey.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to adhere to its policies and procedures for reporting resident-to-resident altercations, resulting in a deficiency. The facility's policy, implemented on April 1, 2024, mandates that all alleged violations involving abuse or serious bodily injury be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, specifically within two hours of the allegation. However, the facility did not comply with these requirements in three separate incidents involving resident-to-resident altercations. In the first incident, an altercation between two residents on December 21, 2024, resulted in a minor injury, but the allegation was not reported to the state agency until two days later. In the second incident, an altercation on November 26, 2024, was reported to the facility administration the following day, but the state agency was not notified until November 30, 2024. Similarly, a third incident on November 28, 2024, was reported to the facility administration an hour after it occurred, but the state agency was not informed until two days later. The facility administrator confirmed that these allegations were not reported within the required timeframe.
Medication Administration Deficiency Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available on the Courtyard unit, leading to a significant medication administration deficiency. On the specified date, the staff schedule showed no nurse or medication aide-certified (MA-C) was assigned to the 6 AM to 6:30 PM shift in the Courtyard unit. As a result, medications were not administered to residents during this period. Interviews with staff members, including CNAs and MA-Cs, revealed that the former Director of Nursing (DON) was supposed to cover the medication administration but failed to do so. Multiple residents were affected by this deficiency. For instance, residents had various medications signed off by the former DON, but these were not administered. The medications included treatments for conditions such as benign prostatic hyperplasia, depression, hypertension, dementia, and constipation. The lack of medication administration led to residents exhibiting behaviors such as pacing, elevated blood pressures, yelling, and threatening others, which were noted by the staff as typical when medications were missed. Interviews with the former DON and other staff members confirmed the oversight. The former DON admitted to being the only nurse in the building and acknowledged that he might have been caught up with other tasks, leading to the failure to administer medications. The administrator and nurse practitioner confirmed that the staff scheduled for the Courtyard unit were not able to administer medications, highlighting a critical staffing and procedural lapse in the facility's operations.
Medication Administration Errors Due to Staff Oversight
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for six out of eight sampled residents, leading to significant medication errors. On a specific day, the former Director of Nursing (DON) signed off on the administration of various medications for these residents, despite evidence suggesting that the medications were not actually administered. This discrepancy was discovered through a review of the medication administration records and staff interviews. Interviews with staff members, including a Certified Nursing Assistant (CNA) and Medication Aide-Certified (MA-C), revealed that no staff member was available to pass medications to residents on the Courtyard unit on the day in question. The MA-C reported that she was instructed to hand over the medication cart keys to another MA-C, who was assigned to a different unit, and that the former DON was supposed to administer the medications. However, the former DON admitted to being the only nurse in the building and stated that he might have been caught up elsewhere, leading to the oversight. Further interviews with the administrator and nurse practitioner confirmed that the former DON was unable to explain why the medications were not administered, despite being signed off. The residents on the Courtyard unit exhibited behaviors consistent with not having received their medications, such as pacing and elevated blood pressures. The administrator was informed of the situation, and it was acknowledged as a serious medication error, with the regional clinical director being notified.
Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to ensure acceptable nutritional status for two residents, both of whom experienced significant weight loss. One resident, with chronic kidney disease, dementia, and dysphagia, lost 18.71% of their body weight over several months. The meal intake records showed numerous instances where meals were not recorded or consumed, and the resident often slept through meals. The dietitian noted that the resident's body mass index was below the desired level and emphasized the need for staff to encourage the resident to be more active during meal times. Another resident, diagnosed with Alzheimer's disease and dementia, lost 11.65% of their body weight. Similar to the first resident, meal intake records indicated many unrecorded meals and low consumption rates. The dietitian confirmed the resident's decline and stressed the importance of staff assistance in getting the resident to the dining room. Interviews with staff revealed that a lack of personnel contributed to the residents' weight loss, as staff were unable to provide necessary assistance during meals. The facility's policy on meal supervision and assistance was not adequately followed, as alternatives and snacks were not consistently offered when meals were refused or not eaten.
Failure to Ensure Privacy and Timely Delivery of Residents' Mail
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods, specifically regarding the handling and delivery of mail. During a group interview, five residents reported that their mail was locked up and not delivered on Saturdays, and that the business office sometimes opened their mail before delivery. The activities director confirmed that she sorted through the mail and took non-postcard or non-junk mail to the business office to be opened. The business office manager, who was new to the facility, admitted to opening mail to determine its destination, as some mail needed to be scanned into the computer for residents' files or involved bills that were paid from residents' accounts. An observation showed a stack of residents' mail on the business office desk, indicating a lack of privacy and timely delivery of mail for residents.
Deficiency in Providing Adequate Personal Hygiene Services
Penalty
Summary
The facility failed to ensure residents received adequate personal hygiene services, specifically in providing showers, for three residents. Resident #8, who had no cognitive impairment and required substantial assistance with bathing, reported not receiving showers routinely due to staffing shortages. The resident's bathing record indicated multiple extended periods without a shower, including a 14-day gap. Resident #25, cognitively intact, preferred weekly showers but experienced a 21-day and a 15-day gap without a shower. Resident #53, with moderate cognitive impairment and dependent on others for bathing, was supposed to receive two showers a week but often did not, as evidenced by a 6-day gap without a shower. Observations noted the resident's greasy hair and long nails, indicating neglect in personal hygiene. Interviews with CNAs and the resident representative confirmed concerns about insufficient staffing levels affecting the ability to provide adequate care, including showers. CNAs reported being unable to complete showers due to other responsibilities and insufficient staffing, with showers only being prioritized when residents exhibited body odor. The facility's leadership acknowledged the issue and had conducted an ad hoc meeting to address bathing concerns, but residents, including resident #8, continued to miss showers even after the meeting.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across three of its four care units, impacting the physical, mental, and psychosocial well-being of the residents. Observations and interviews revealed that staff were unable to respond promptly to residents' needs, such as repositioning a resident in a wheelchair and assisting residents in the bathroom. Residents reported long wait times for assistance, with one resident waiting 30 minutes for help in the bathroom and another missing a doctor's appointment due to the lack of available staff. Several residents reported not receiving regular showers, with records showing significant gaps between bathing days. One resident went without a shower for up to 21 days, while another had greasy hair and long nails due to infrequent bathing. Interviews with CNAs confirmed that staffing levels were insufficient to complete all necessary care tasks, including showers, bed-making, and meal service. The facility continued to admit new residents despite the staffing shortages, further exacerbating the issue. The facility's staffing schedules for July, August, and September showed multiple days where the minimum staffing requirements were not met. The administration acknowledged the staffing concerns, attributing them to recent staff turnover and departures for school. The facility attempted to cover nursing positions with medication aides, but these aides were not assigned to direct resident care. The staff scheduler included resident assistant hours in the daily staffing totals, although it was unclear if this was appropriate.
Medication Labeling Deficiency in Medication Carts
Penalty
Summary
The facility failed to ensure that medications available for resident use were labeled appropriately in two of the five medication storage areas, specifically the Rock Creek Hall and Deer Hall medication carts. During observations, it was noted that several insulin pens, including Novolog, Lantus SoloStar, Toujeo SoloStar, and Basaglar, were opened and undated, despite the availability of yellow stickers for labeling in the top drawer of the carts. Interviews with staff, including two LPNs and the DON, revealed that the facility's policy required all insulin pens to be labeled with a yellow sticker, indicating the open date, expiration date, and initials of the person who opened it. The policy also stated that insulin pens should be discarded 28 days after opening. The deficiency was further highlighted by the staff's acknowledgment of the labeling requirements and their failure to adhere to them. The LPNs admitted that the insulin pens should have been labeled with the necessary information, and the DON confirmed that all nurses were responsible for labeling and dating multidose vials upon opening. The facility's policy on labeling medications and biologicals, dated April 16, 2024, was reviewed and confirmed the requirement for labels to include the date the vial was initially opened or accessed.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor a resident's advance directive choice, resulting in a discrepancy between the resident's documented code status and their expressed wishes. The electronic medical record for a resident indicated a code status of 'Full Code,' which was confirmed by a physician's note and active physician orders. However, a WyoPOLST form signed by the resident indicated a preference for 'DNR/Do Not Attempt Resuscitation (Allow Natural Death).' An interview with the Director of Nursing confirmed that the resident had elected a DNR status, but the electronic health record incorrectly reflected a Full Code status. This inconsistency highlights the facility's failure to ensure the resident's choice for advance directives was accurately documented and followed.
Inaccurate PASARR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate preadmission screening and resident review (PASARR) for two residents with qualifying diagnoses of mental disorders. Resident #8, who had diagnoses including depression and bipolar disease, was found to have a PASARR Level I assessment that incorrectly indicated no evidence of mental illness, despite having a qualifying diagnosis of mood disorder. This error resulted in the absence of a necessary PASARR Level II evaluation. Similarly, Resident #59, with diagnoses of bipolar disorder and depression, had inconsistencies in their PASARR Level I assessments. An initial assessment indicated a major mental illness and a categorical determination for convalescent care, requiring a Level II determination if the stay extended beyond 120 days. However, a subsequent assessment incorrectly marked no evidence of mental illness. These deficiencies were linked to issues with the duties performed by the social services director, who was responsible for PASARR completion and was subsequently terminated.
Latest citations in Wyoming
A facility failed to keep residents’ personal and medical records secure and confidential. Medical record review showed hospice notes were entered directly into the EMR for three residents, and the regional clinical director stated the hospice previously used was given full access to the EMR for all residents. The Resident Rights policy stated residents have a right to secure and confidential personal and medical records.
Failure to Offer Choice of Hospice Provider: The facility did not ensure that 3 residents receiving hospice services were offered a choice of hospice provider. Medical record review showed no evidence that the residents were given provider choice, and an RCD confirmed that prior to the operator transition, hospice residents were not given a choice. The facility's Resident Rights policy states residents have the right to choose health care and providers of health care services.
Failure to Assess and Document Changes in Condition: A resident with repeated falls, hypoxia, lethargy, and later hospital transfers had multiple episodes where assessments, vital signs, or follow-up documentation were missing or delayed. Another resident with COPD and impaired gas exchange was observed in respiratory distress without oxygen and was later transferred for respiratory failure, with no transfer documentation on the progress notes. A third resident with dementia and a history of falls had incomplete post-fall assessments and was later sent to the hospital after additional falls and pain. A fourth resident with a Foley catheter had cloudy, low, and absent output, pain, and family requests for transfer; the catheter was later found to have caused traumatic injury and hematuria.
Opened medications in two medication fridges were found without required opened-on or discard dates. An Ozempic pen in one fridge and an opened Tubersol vial plus an opened Ativan oral solution in another fridge were all in use but unlabeled, and staff confirmed the missing dates. The DON stated she expected in-use multi-dose vials to have an opened-on or discard-by date, and manufacturer guidance reviewed for these medications specified discard timelines after opening.
A facility failed to ensure hospice services met professional standards for 3 sampled residents. Medical record review showed each resident was receiving hospice services, but none of the records contained a physician order for hospice referral or eval. An RCD confirmed that residents placed on hospice did not receive a physician order for eval and that the hospice used at the time had access to all resident medical records.
Infection control was not maintained during meal service and resident care. A CNA touched hair, clothing, and other surfaces while handling meal tickets, food, and drink cups without hand hygiene, including placing chips on a resident’s burger and touching cup rims. Staff also left visibly soiled linens in place for a resident with bowel incontinence, and oxygen cannulas/tubing for multiple residents were found on the floor or unlabeled, with one cannula picked up from the floor and placed on a resident.
A facility failed to ensure pneumococcal immunization status was assessed for 5 of 5 sampled residents. Medical record review showed no evidence that PCV had been assessed or offered, and the IP confirmed there was no documentation of pneumococcal vaccination status. The facility reported its immunization process tracked vaccines on admission and documented annual COVID and influenza vaccines, but the pneumococcal audit had been delayed because records could not be accessed.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
Failure to Investigate Allegation of Verbal Abuse: A volunteer reported that an activities staff member yelled at a resident during bingo and then yelled at the volunteer when she intervened. Interviews with the resident and volunteer confirmed the staff member spoke rudely and loudly to the resident, and the regional clinical director confirmed there was no evidence the verbal abuse allegation was reported or investigated.
Failure to Allow Return After Hospital Transfer: A resident was transferred to the ER for altered mental status and increased confusion, but the facility did not provide a transfer/discharge notice and did not allow the resident to return after the acute hospitalization. The DON stated the decision not to permit return was financial, while the business office manager believed it was due to insufficient staffing. The facility policy stated residents transferred to acute care will be permitted to return upon discharge, and not permitting return constitutes a discharge.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained secure and confidential. Medical record review showed that resident #26 received hospice services beginning on 1/2/26, resident #83 received hospice services beginning on 1/21/26, and resident #84 received hospice services beginning on 2/5/26, and the hospice provided documented notes directly into the electronic medical record system. During interview on 5/6/26 at 12:44 PM, the regional clinical director stated the only hospice used prior to a change in operator was given full access to the electronic medical record for all residents. Review of the facility’s Resident Rights policy stated residents have a right to privacy and confidentiality of personal and medical records and the right to secure and confidential records.
Failure to Offer Choice of Hospice Provider
Penalty
Summary
The facility failed to ensure residents' right to choose their health care providers for 3 of 12 sampled residents reviewed for hospice services. Resident #26 began receiving hospice services on 1/2/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but the medical record review showed no evidence that any of these residents were offered a choice in hospice provider. During an interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that prior to the operator transition, residents on hospice were not given a choice for hospice provider. The facility's Resident Rights policy, last revised on 6/10/25, states that the resident has the right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care.
Failure to Assess and Document Changes in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for four residents who experienced changes in condition. For resident #1, the record showed multiple episodes where the resident was found after falls, had low oxygen saturations, became lethargic, or was unresponsive, yet there was no evidence of timely assessments, vital signs, or follow-up documentation at several of those events. The record also showed a late entry note for a 3/5/26 incident was added 62 days after the event. The resident was later transferred to the hospital for respiratory failure, pneumonia, acute heart failure, dry gangrene, hyponatremia, metabolic encephalopathy, pulmonary edema, critical electrolyte abnormalities, atrial fibrillation with RVR, and acute kidney injury. For resident #69, the resident had diagnoses including chronic myeloid leukemia, CAD, seizure disorder, traumatic brain injury, and COPD, and the care plan addressed impaired gas exchange. On 5/4/26, the resident was observed sitting on the edge of the bed with a respiratory rate of 30-40 breaths per minute, grey pallor, and no oxygen in place. The resident was later sent to the hospital for respiratory failure, but the progress notes for the transfer did not show documentation on 5/5/26. A later facility note stated the resident had been found with oxygen saturation of 60% on 4 lpm NC, difficulty breathing, and lethargy, and the LPN reported she had been asked to come in on her day off to document the assessment and transfer. For resident #81, who had severe cognitive impairment, dementia, COPD, atrial fibrillation, CAD, diabetes, and a history of falls, the record showed repeated falls and incomplete assessments. After a fall on 4/20/26, the assessment section was left blank. Another note dated 4/23/26 documented pain, confusion, and unsteadiness but stated there were no safety risks. After a fall on 4/25/26, staff documented vital signs and a normal assessment but did not know whether the resident hit his/her head, and there was no evidence of follow-up assessments. After a fall on 4/30/26, the resident was found on the floor with pain, and the interdisciplinary review identified impaired cognition, weakness, and self-transfers as the root cause, with a new skin tear noted. The resident's representative reported the resident was in significant pain, not at baseline, disheveled, saturated with urine, had neck swelling, and was missing a pain patch, and stated no vital signs or assessment had been done before the resident was sent to the hospital. For resident #6, who had moderate cognitive impairment, cancer, CAD, heart failure, renal disease, dementia, and an indwelling catheter, the care plan identified UTI risk related to the Foley catheter. After a recent hospitalization for sepsis related to UTI/prostate cancer, the record showed thick cloudy catheter output, complaints of pain, and periods of no catheter output. The resident's family repeatedly requested hospital transfer, and the catheter was changed after the resident had no output since the prior shift; the catheter then drained but had bloody urine. The resident later had cloudy grayish-yellow urine, was not getting up for breakfast, and was transferred to the ED. The ER report stated the Foley had caused traumatic injury and hematuria because the balloon was inflated in the prostatic urethra, and the resident also had AKI with creatinine elevated above baseline. The DON stated she expected transfer documentation to include resident condition, vital signs, notifications, and immediate or within-24-hour documentation, and confirmed that only vital signs were completed and ongoing assessment was not completed as expected.
Medication Labeling Deficiency in Two Medication Fridges
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles because opened medications in two medication refrigerators did not have an opened-on or discard date. During observation in the Rock Creek medication fridge, an Ozempic 8 mg/3 ml pen was found with no opened-on or discard date. MA-C #1 confirmed the Ozempic pen had been opened and used the day before and that no date had been written on it. In the secure unit fridge, an opened Tubersol vial and an opened Ativan oral solution 2 mg/ml were observed without opened-on or discard dates. LPN #2 confirmed both medications were in use and that neither had the required dates. The DON stated she expected an opened-on or discard-by date to be written on in-use multi-dose vials. Manufacturer instructions reviewed for Ozempic, oral liquid Lorazepam, and Tubersol specified time limits for use after opening, and the facility policy required multi-use vials to include the date initially opened or accessed.
Missing Physician Orders for Hospice Referrals
Penalty
Summary
The facility failed to ensure hospice services met professional standards for 3 of 12 sampled residents. Medical record review showed that resident #7 began receiving hospice services on 3/31/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but none of the three records contained evidence of a physician order for a hospice referral or evaluation. During interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that residents placed on hospice did not receive a physician order for evaluation and that the hospice used at that time was given access to the medical record for all residents.
Infection Control Lapses During Dining, Linen Care, and Oxygen Equipment Handling
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for resident care and meal service. During dining room observation, a CNA touched his hair, handled resident meal tickets, and repeatedly handled resident food and drink items with exposed hands without performing hand hygiene between tasks. The CNA placed a bag of chips on top of a resident’s hamburger, touched the top bun to apply jelly, handled drink cups by the rims, and continued passing trays after touching his pants, hair, and other surfaces. The infection preventionist and DON confirmed staff were expected to perform hand hygiene after touching hair, skin, or clothing and that the CNA should not have touched resident meal items without hand hygiene. The facility also failed to manage soiled linens and oxygen equipment for residents with visible contamination or tubing on the floor. One resident had linens visibly soiled with bowel movement incontinence, yet the blanket was pulled over the sheets, the soiled linen remained visible during later observations, the resident lay on top of an oxygen cannula on the soiled sheets, and housekeeping picked up the cannula from the floor and placed it on the resident. Two other residents had nasal cannulas or oxygen tubing on the floor or unlabeled, including tubing dated 4/19/26 and tubing labeled 5/3/26 that remained on the floor during repeated observations. The IP confirmed oxygen tubing should be changed and labeled weekly and as needed or when visibly soiled, that cannulas found on the floor should not be used on residents, and that soiled linens should be changed immediately.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure residents were immunized for pneumococcal disease for 5 of 5 sampled residents (#66, #69, #1, #33, and #4) reviewed for current vaccination status. Medical record review showed no pneumococcal conjugate vaccine had been assessed or offered for these residents. The infection preventionist confirmed there was no evidence of pneumococcal vaccination status, and also stated the facility’s immunization process assessed and tracked vaccines on admission, with annual COVID and influenza vaccines offered and documented, but that the pneumococcal vaccine audit had been delayed because records could not be accessed. CDC guidance reviewed by surveyors indicated that adults age 19 years or older with unknown or no prior PCV history should receive PCV15, PCV20, or PCV21.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for resident #55. A complaint/grievance form documented that a volunteer reported activities staff member #1 yelled at resident #55 during bingo after the resident called out bingo, and the volunteer stated the staff member continued yelling at the resident and then yelled at the volunteer when she intervened. The grievance also noted that two residents reported the activities staff member yelled at them all the time and spoke to them the same way during bingo. Interviews confirmed the incident involved rude and loud comments by the activities staff member toward resident #55 during bingo, including telling the resident to stop interrupting and making a smart-ass remark. Resident #55 stated the interaction upset him/her and that the staff member was later terminated. A volunteer corroborated hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was investigated.
Failure to Allow Return After Hospital Transfer
Penalty
Summary
The facility failed to ensure resident #82 was allowed to return after an acute hospitalization. A progress note dated 3/11/26 at 8:33 PM documented that the resident was transferred to the hospital emergency room for altered mental status and increased confusion. The medical record showed no evidence that a transfer/discharge notice was provided at the time of transfer. A discharge MDS assessment showed the resident’s return to the facility was anticipated and that the discharge was unplanned, with a discharge status of Short-Term General Hospital (acute hospital, IPPS). Interviews confirmed the resident did not return to the facility after the hospital transfer. The DON stated on 5/7/26 at 9:45 AM that the decision not to allow the resident to return was financial, and also confirmed that no discharge notice was provided after transfer and that the facility did not assist in finding alternate placement. The business office manager stated on 5/7/26 at 10:54 AM that the resident was not allowed to return following the hospital transfer, although he believed the reason was insufficient staffing. The facility policy stated that residents transferred to acute care will be permitted to return upon discharge and that not permitting a resident to return following hospitalization constitutes a discharge.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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