Casper Mountain Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Casper, Wyoming.
- Location
- 4305 S Poplar, Casper, Wyoming 82601
- CMS Provider Number
- 535024
- Inspections on file
- 41
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 68
Citation history
Health deficiencies cited at Casper Mountain Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident was discharged to a hospital and did not return, and the resident’s representative later requested a full set of medical records for a defined date range, including progress notes, labs, imaging, diagnostic test results, nursing notes, and clinical summaries. The facility’s medical record request log confirmed the request, but the records supplied contained progress notes only up to a point several days before the resident’s discharge, and the representative reported that she initially received only hospital records and then an incomplete facility record set missing several days of documentation. The medical records director stated the initial request occurred before the representative became POA and that records were picked up once POA status was established, while the NHA acknowledged there was no reason the representative could not receive all requested records, despite facility policy requiring staff to verify the accuracy of the requested date range.
Surveyors found that a resident with intact cognition but multiple medical conditions and total dependence for transfers had an ADL care plan that was incomplete and not patient-centered. Although the plan noted dependence in areas such as bathing, bed mobility, dressing, and transfers, key elements were left as blanks or placeholders, including specific bathing preferences, level of assistance (e.g., supervision, extensive, dependent), number of staff needed, type of assistance, and frequency of care. The MDS nurse acknowledged that the care plan lacked the necessary detail to be complete and individualized.
A resident with intact cognition and multiple medical conditions, including septicemia, DM, and cellulitis, was care planned as dependent for all ADLs and transfers. Observation showed a CNA transferring the resident from a wheelchair to bed using a full-body mechanical lift without a second staff member, contrary to facility policy requiring two staff for mechanical lift transfers. The resident reported not getting into the wheelchair on some days due to insufficient staff. The DON confirmed the two-person requirement for mechanical lift use, and the administrator stated he was unaware that residents were remaining in bed because of staffing and described the issue as related to teamwork.
Surveyors found that staff failed to follow infection prevention practices under enhanced barrier precautions during wound care for two residents. One resident with multiple venous/arterial leg ulcers and moderate serous exudate received an Unna boot dressing change where the wound nurse wore gloves but no gown. Another resident with a post-surgical abdominal incision had a dressing change performed without the nurse wearing a gown. The wound nurse acknowledged not using gowns and described EBP as only involving gloves and hand hygiene, while the infection control nurse reported expectations for EBP in certain procedures. The facility’s infection prevention and control policy lacked guidance on enhanced barrier precautions.
A resident with multiple physical limitations who used an electric wheelchair sustained a fractured leg after getting caught in a doorway and later suffered a large bruise from bumping into a bed. Despite these incidents, no wheelchair safety assessments were completed, and the care plan was not updated with additional interventions. Staff interviews confirmed that safety assessments should have been performed for residents using power wheelchairs.
A resident with severe cognitive impairment and multiple chronic conditions was admitted at risk for pressure ulcers but did not receive timely or documented wound care after developing several pressure ulcers. Despite physician notes and nursing evaluations identifying new ulcers, necessary treatment orders and interventions were delayed, and there was no evidence of wound care prior to the resident's discharge after being sent to the emergency room.
Staff did not follow infection control protocols, as a resident's catheter bag was repeatedly placed on the floor, and the facility failed to implement its Legionella water management program. Additionally, an outbreak of gastrointestinal illness affecting 14 residents was not reported to the state licensing agency, and the interim DON was unaware of the reporting requirement.
Three cognitively intact residents were not included in the development or implementation of their person-centered care plans, as evidenced by their lack of recall of care conference invitations and absence of documentation showing their participation, despite facility policy requiring such involvement. The DON confirmed that while care conferences were held, there was no evidence of resident participation.
The facility did not provide required written transfer notices or bed-hold policy information to several residents or their representatives prior to hospital transfers, and failed to notify the State LTC Ombudsman as required. Documentation of these actions was missing or incomplete, and facility policy procedures for notification and record-keeping were not followed.
Surveyors observed that a soiled fan was blowing onto a food preparation counter where food was being handled, and a rack for clean utensils was placed near dirty pipes behind the cooking area. The fan and the area behind the grill/oven were confirmed to be unclean, and the latter was not included on the cleaning schedule.
The facility did not maintain documentation showing that residents were educated on the benefits and risks of the COVID-19 vaccine or that consent or refusal forms were completed, as required by facility policy. Medical record reviews and staff interviews confirmed the absence of this documentation for several residents who were not up-to-date on vaccination.
The facility did not ensure that advance directives were accurately formulated and documented for two residents. In one case, a resident was listed as DNR in the EMR without a signed and dated advance directive, and in another, the EMR showed full code status despite a signed form indicating no CPR. Staff confirmed discrepancies between documentation and residents' expressed wishes.
Two residents were found to be receiving psychotropic medications without proper documentation of risk-benefit analysis, gradual dose reduction attempts, or clinical rationale for continued use. The facility was unable to provide required documentation for antipsychotic and antianxiety medications, and a PRN order lacked a stop date. The DON confirmed gaps in the psychotropic medication review process and missing documentation.
Surveyors identified that MDS assessments were not accurately completed for three residents. One resident with multiple psychiatric diagnoses was incorrectly marked as not having a serious mental illness per PASRR Level II, and another resident's functional status section (GG) was left unassessed due to lack of available staff. These deficiencies were confirmed through record review and staff interviews.
A resident with schizophrenia who was receiving antipsychotic, antianxiety, and antidepressant medications did not have documented monthly medication reviews or pharmacist recommendations for several months. Review of medical records and the interim DON's binder showed no evidence that the required pharmacist reviews were performed or documented, and staff confirmed the missing documentation.
A resident who declined both influenza and pneumococcal vaccines did not have documentation in the medical record showing that education on vaccine benefits and risks was provided, nor was there a record of consent or refusal, as required by facility policy. Interviews with the DON and ADON confirmed the absence of this documentation.
The facility did not correctly issue required NOMNC and SNF ABN forms for two residents, with errors including missing reasons for non-coverage, missing estimated costs, and incorrect resident names on forms. Staff confirmed the forms were inaccurate and did not meet policy requirements for informing residents or their representatives about Medicare coverage changes and potential financial liability.
A resident with multiple non-pressure wounds did not receive consistent wound care as ordered, with missed dressing changes, lack of wound monitoring, and incomplete documentation. The wounds worsened over time, and the resident was eventually hospitalized with sepsis and cellulitis related to the untreated wounds. Staff interviews and record reviews confirmed a lack of oversight and documentation for wound care, resulting in actual harm.
Two residents received wound care from a MA-C who applied topical solutions and dressings to open wounds without performing wound assessments or measurements, and without clear evidence that such care was within the MA-C's legal scope of practice. Facility staff were unable to provide competencies for MA-Cs in wound care, and state nursing board guidance indicated that MA-Cs are not permitted to apply medications to wounds.
A medication aide-certified performed wound care for a resident with open wounds without wearing a gown, despite the resident being on enhanced barrier precautions and personal protective equipment being available. Facility policy and the infection preventionist confirmed that both gloves and gowns are required for residents with wounds.
A resident with multiple serious diagnoses was not provided their prescribed Nifedipine ER dose at bedtime following readmission, as the medication was unavailable and not administered until the next morning. Facility staff could not confirm the medication was obtained from the stat lock or properly documented, and the physician was not notified of the missed dose.
A resident's right to receive visitors was not upheld when the facility issued a no trespass order against the resident's friend after a verbal altercation with another resident. The friend was banned from visiting despite the behavior not meeting the facility's policy criteria for restricting visitation, and no less restrictive alternatives were considered.
A resident with heart failure and diabetes developed new lower extremity edema and a venous wound on the left foot, as documented in skilled nursing and wound evaluations. Despite these significant changes, there was no evidence that the resident's physician was notified, and no physician orders were present for wound care. Interviews confirmed that only the wound care team was informed, not the resident's physician.
Two residents with wounds did not receive care in accordance with physician orders or professional standards. One resident with a venous foot wound was treated by a physical therapist without physician notification or orders, and another with a surgical wound did not have physician orders or documentation for required daily dressing changes. The DON confirmed these lapses, and facility policy requiring physician involvement was not followed.
A resident with a history of falls and no reported pain was given Tramadol routinely instead of as needed (PRN) due to a transcription error. The medication was administered multiple times despite the resident having a pain level of zero, and family members expressed concern about the frequency and effects of the drug. The DON confirmed the order was incorrectly entered as routine rather than PRN.
A resident with Alzheimer's and impaired cognition had missing hearing aids for two years, with family repeatedly voicing concerns during care plan meetings. The facility failed to document or address the grievance, and staff were unaware of the issue. The facility's grievance policy was not followed, and no inventory of the resident's belongings was available.
A facility failed to implement a comprehensive care plan for a resident with moderately impaired cognition and Alzheimer's dementia. The care plan required ensuring hearing aids were in place, but records indicated the resident did not own hearing aids. Observations confirmed the resident was not wearing hearing aids, and staff interviews revealed no history of the resident using them. The administrator could not find an inventory of the resident's belongings upon admission.
The facility failed to maintain a sanitary kitchen environment, with a non-working handwashing sink and a dirty floor under the dishwasher. The cleaning schedule was not followed, and the dishwasher did not consistently reach the required sanitization temperatures. Staff were aware of these issues, but they persisted, posing a risk of contamination.
The facility failed to have a licensed administrator on-site, as the current administrator lived in a different town and was employed elsewhere. Observations showed an unlicensed administrator in training managing the facility, while the licensed administrator communicated via email and phone. The previous administrator was on leave, and the current administrator had never visited the facility.
The facility failed to maintain the Ecolab ES-4000 dishwasher at the required temperature, as observed in the kitchen. Dietary aides reported water temperatures below the recommended 120 degrees Fahrenheit, with logs showing compliance only a few times. The facility's policy and FDA guidelines emphasize the importance of maintaining specific temperatures for effective sanitization, yet the issue persisted despite awareness by maintenance and the Ecolab technician.
A facility failed to follow infection prevention guidelines during meal service in the sunflower dining area. A resident with memory impairment and dysphagia required assistance with eating, but instead, other residents attempted to help, including touching the resident's food with bare hands. The dietary staff did not intervene, and no facility staff provided the necessary assistance or cues as per the care plan. Interviews confirmed that such actions were inappropriate and against infection control policies.
A facility failed to provide a resident with the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) forms in a timely manner. The resident's Medicare Part A stay ended without evidence of these notices being issued, as confirmed by the business office manager. The facility's policy requires these forms to be used to inform residents about their rights to appeal or request expedited determinations.
A facility failed to conduct a required PASARR Level II assessment for a resident with moderate cognitive impairment and psychiatric diagnoses. The resident's PASARR Level I assessment indicated the need for a Level II determination if the stay exceeded 120 days, but no such assessment was found. The DON noted that social services were responsible for PASARR assessments, but the facility lacked social services staff and a PASARR policy.
A resident with memory impairments and multiple diagnoses required assistance with eating, as per their care plan. During a dining observation, the resident did not receive necessary help from staff, leading other residents to attempt assistance. The dietary staff and DON present did not intervene, contrary to facility policies on meal supervision and individualized care plans.
Expired medications were found in a medication cart, including an insulin Aspart flex pen and a Basaglar insulin pen without expiration dates. An RN confirmed these were for resident use and should have been dated when removed from the refrigerator. The DON stated that staff were expected to label insulin pens with an open date, which was not done. Facility policies required identifying expiration dates and disposal after 28 days, as confirmed by manufacturer guidelines.
The facility failed to provide accurate daily staff postings over a two-week period, combining LPN and MA-Cs data on one line. An observation and review confirmed this issue, and the DON acknowledged the error, stating they should have been counted separately.
The facility failed to ensure the DON was licensed by the State of Wyoming before providing nursing care. The former DON, hired without a valid license, performed nursing tasks for five residents, including assessments and documentation. Despite being aware of the licensing issue, the facility allowed the DON to provide care. The DON was later granted a license but was terminated shortly after.
Failure to Provide Complete Medical Records to Resident Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide a complete copy of a resident’s medical record to the resident’s legal representative after a formal request. The resident was admitted on an admission MDS assessment dated with a specific date and was discharged to the hospital on 1/4/26, not returning to the facility afterward. The resident’s representative requested the resident’s medical records on 2/2/26 for the date range 10/31/25 through 1/4/26, including progress notes, lab results, imaging, diagnostic testing results, nursing notes, and clinical summaries. Review of the records that were actually provided showed that progress notes were only supplied through 12/27/25, leaving a gap from 12/28/25 through 1/4/26. The resident’s representative reported that after one month she initially received only the hospital records, and it took an additional week and a half to obtain records from the facility, which still lacked documentation from 1/1/26 through 1/4/26. She stated she was unable to get any further response to obtain the complete set of records. The medical records director stated that the representative had first requested the records before she was the resident’s POA and that the documents were picked up on 2/26/26, the date the representative became POA. The NHA confirmed there was no reason the resident’s representative could not receive all of the records. Review of the facility’s policy on Authorization for Release of PHI showed that staff must confirm the accuracy of the date range, but the requested date range was not fully honored in the records provided.
Incomplete and Non–Patient-Centered ADL Care Plan for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the development and implementation of a comprehensive, patient-centered care plan for one resident. Medical record review showed that this resident had intact cognition with a BIMS score of 15/15 and diagnoses including septicemia, diabetes mellitus, and cellulitis of the left lower limb, and was dependent for all transfers. The resident’s care plan, initiated in early February and revised in March, documented that the resident had an ADL self-care performance deficit and was dependent for multiple self-care tasks, including bathing, transfers, personal hygiene, bed mobility, dressing, eating, toilet use, ambulation, and locomotion related to obesity, infection, and wounds. However, multiple sections of the care plan were incomplete and lacked the specific, measurable details required for implementation. The bathing preference care plan failed to specify whether the resident preferred showers or bed baths, the days or shifts for bathing, or the preferred caregiver gender. The bathing/showering, bed mobility, dressing, and transfer care plans all contained placeholders such as “SPECIFY” and did not indicate the level of assistance (e.g., supervision, limited, extensive, dependent), the number of staff required, the type of assistance needed, or the frequency of assistance. During an interview, the MDS nurse confirmed that the care plan was incomplete and not patient-centered.
Failure to Use Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment during mechanical lift transfers for a resident who was dependent for all transfers. The resident’s admission MDS showed a BIMS score of 15/15, indicating intact cognition, and diagnoses including septicemia, diabetes mellitus, and cellulitis of the left lower limb. The resident’s care plan, last revised on 3/8/26, documented that the resident was dependent with all ADLs, including transfers, related to obesity, infection, and wounds. On 4/22/26 at 4:08 PM, observation showed a CNA transferring this resident from a wheelchair to the bed using a full-body mechanical lift without the assistance of another staff member. In an interview the following day, the resident reported not getting into the wheelchair every day, stating that some days there was not enough staff. The DON stated in an interview that two staff members should be used when performing transfers with a full-body mechanical lift. The administrator reported he had not heard that residents were staying in bed due to lack of staff to provide two-person assistance with the Hoyer lift and described it as a teamwork issue, noting that nurses were also available to help. Review of the facility’s “Safe Resident Handling/Transfers” policy dated 1/1/26 confirmed that two staff members must be utilized when transferring residents with a mechanical lift.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate infection prevention and control practices, specifically the use of personal protective equipment (PPE) under enhanced barrier precautions (EBP), during wound care for two residents. One resident had intact cognition and diagnoses including chronic venous hypertension with ulcer and inflammation of both lower extremities, with four venous/arterial ulcers present. The resident’s care plan documented multiple wounds on the left lower leg, and the medical record showed a left lower leg wound with moderate serous exudate. During an observation of wound care, the wound nurse applied an Unna boot dressing to the resident’s left lower leg while wearing gloves but did not wear a gown. Another cognitively intact resident had a diagnosis including unspecified abdominal hernia with obstruction and a care plan for post-surgical wound management of a midline abdominal surgical incision. During an observed dressing change to the upper quadrant of this resident’s abdomen, the wound nurse again did not wear a gown. In a subsequent interview, the wound nurse confirmed she had not been using gowns when performing wound care and described her understanding of EBP as involving only gloves and hand hygiene. The infection control nurse stated she expected EBP to be used for procedures such as changing ostomy bags, G-tubes, and Foley catheters and reported she was in the process of writing a new policy. Review of the facility’s Infection Prevention and Control Program policy, last updated in 2018, showed no guidance on enhanced barrier precautions.
Failure to Assess and Address Wheelchair Safety After Resident Injuries
Penalty
Summary
The facility failed to evaluate and address hazards and risks for a resident who was cognitively intact but had significant physical limitations, including diabetes mellitus, morbid obesity, muscle weakness, and gout. The resident required the use of an electric wheelchair for mobility. Despite these risk factors, the facility did not complete a wheelchair skill or safety assessment after the resident sustained a right leg fracture in June, which occurred when the resident's leg became caught in a courtyard doorway while using the wheelchair. Medical documentation confirmed the injury, including an orthopedic note and X-ray results showing an acute, nondisplaced oblique fracture of the distal tibial diaphysis. Additionally, the resident experienced a large bruise to the left calf after bumping into a bed with the wheelchair in October. Interviews with both the resident and the Physical and Occupational Therapy Director confirmed that no wheelchair safety assessments were conducted following either incident. The care plan only included an intervention to educate the resident on proper use of mobility devices, with no further interventions or assessments added after the injuries. An RN confirmed that safety assessments should have been completed for all residents using power wheelchairs.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and heart failure, was admitted without any existing wounds but was identified as being at risk for pressure ulcers. Despite this risk, the facility failed to implement and document appropriate wound care and monitoring. Physician notes indicated the development of an unstageable pressure ulcer on the resident's right buttocks, but there were no corresponding treatment orders or evidence of wound care in the medical record. Subsequent nursing evaluations documented additional pressure ulcers on the resident's heels, left medial calf, and coccyx, with delayed notification and action from the nursing staff and DON. Further review revealed that orders for necessary interventions, such as the use of prevalon boots and wound care, were not added until several days after the ulcers were identified. The resident's representative reported that the resident was sent to the emergency room for another issue, where concerning pressure ulcers were found, and the resident did not return to the facility. The interim DON confirmed that there was no documentation of wound care or treatment prior to the resident's discharge, indicating a failure to provide timely and appropriate pressure ulcer prevention and treatment.
Failure to Implement Infection Control, Water Management, and Outbreak Reporting
Penalty
Summary
Staff failed to implement and maintain effective infection prevention and control practices in several areas. During observation, a resident with a catheter was found with the catheter bag lying flat on the floor on two separate occasions. A CNA stated that the bed did not have a place to hang the bag, so it was placed on the floor. Both the interim DON and ADON confirmed that catheter bags should not be placed directly on the floor. Additionally, the facility did not implement its water management program for Legionella, as required by its own policy, and failed to maintain logs or review data for trends or deficiencies. An outbreak of gastrointestinal illness involving 14 residents was not reported to the state licensing agency, despite the requirement to do so. The interim DON was unaware of the reporting requirement at the time of the survey.
Failure to Include Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to include residents in the development and implementation of their person-centered care plans for three out of five sampled residents, all of whom were assessed as cognitively intact with BIMS scores of 15 out of 15. Interviews with these residents revealed that they either did not recall being invited to care conferences or had only been invited once, despite multiple care plan revisions and assessments occurring during their stays. Medical record reviews confirmed that care conferences were either not documented as occurring at appropriate intervals or lacked evidence of resident participation. Further review of facility policy indicated that residents and/or their representatives should be included in care plan discussions at regular intervals and after significant changes, with signatures obtained to confirm participation. However, interviews with the interim DON confirmed that while care conferences were held quarterly, there was no evidence that residents participated in the planning process as required by policy. This lack of resident involvement was consistently observed across the sampled cases.
Failure to Provide Required Transfer Notices and Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide required written notices of transfer and information on bed-hold policies to residents and/or their representatives prior to facility-initiated hospital transfers for three out of five sampled residents. Specifically, there was no evidence that written transfer notices or bed-hold policy information were given to the residents or their representatives for multiple transfers. In some cases, the transfer notices were not signed by the facility representative, and there was no verification of receipt by the resident or responsible party. Additionally, the facility did not send copies of the transfer notices to the Office of the State Long-Term Care Ombudsman as required. Interviews with the Nursing Home Administrator confirmed the absence of documentation showing that the required notices were provided or that the Ombudsman was notified. Policy reviews indicated that the facility's procedures require written information on bed-hold practices to be provided both in advance and at the time of transfer, with documentation of attempts to notify representatives. However, these procedures were not followed, as evidenced by the lack of signed and dated copies of the notices in the residents' medical records and the failure to notify the Ombudsman.
Unsanitary Food Preparation Area and Inadequate Cleaning Practices
Penalty
Summary
The facility failed to maintain a sanitary environment in the food preparation area, as observed during surveyor visits. An upright fan, which was visibly darkened and soiled with debris, was found blowing directly onto a food preparation counter where a cutting board and knife were present. Additionally, a rack used for storing clean utensils and cookware was located directly behind the hooded gas cooking area, with visibly dirty and soiled pipes situated between the grill/oven and the storage rack. On a subsequent observation, the same unclean fan was again blowing on the food preparation area while a dietary aide was preparing individual syrup cups for residents. The dietary manager and cook confirmed the fan was not clean, and the area behind the grill/oven remained unclean. The dietary manager also confirmed that the area behind the grill/oven was not included on the cleaning schedule. No information about specific residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to maintain a system for documenting that residents were provided education regarding the benefits and potential side effects of the COVID-19 vaccination, as well as documentation of consent or refusal for the immunization. Medical record reviews for four sampled residents revealed that there was no evidence these individuals received education about the COVID-19 vaccine, nor was there a copy of a consent or declination form maintained in their records. Each of these residents was noted as not being up-to-date on the COVID-19 vaccination according to their most recent MDS assessments. Interviews with the interim DON and ADON confirmed that no further documentation was available to demonstrate compliance with the facility's own policy, which requires education and signed consent prior to vaccination. The policy also specifies that education should be provided in a language and format understood by the resident or their representative, and that documentation and reporting are overseen by the infection preventionist. Despite these requirements, the necessary documentation was not present for the residents reviewed.
Failure to Accurately Formulate and Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly formulated and accurately documented for two residents. For one resident, the electronic medical record (EMR) indicated a do not resuscitate (DNR) status, but there was no evidence in the medical record that the resident had signed and dated an advance directive, and staff confirmed there was no documentation of the resident electing DNR status. For another resident, the EMR listed a full code status, but a CPR designation form signed and dated by the resident indicated a preference for no CPR, and staff confirmed that the EMR did not reflect the most recent election of no CPR. Review of facility policy showed requirements for inquiry and documentation of advance directives upon admission and ensuring the plan of care is consistent with documented treatment preferences, which were not followed in these cases.
Failure to Ensure Unnecessary Psychotropic Medications Are Avoided
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications for two of five residents reviewed. For one resident with a diagnosis of schizophrenia, the medical record showed ongoing prescriptions for antipsychotic and antianxiety medications, but the facility could not provide documentation of a required risk-benefit statement signed by the physician or evidence supporting a gradual dose reduction (GDR) as indicated in the assessment. Additionally, a physician order for PRN lorazepam lacked a stop date, and the interim DON confirmed that the GDR documentation could not be located and that the psychotropic medication review process was still being organized. For another resident with a diagnosis of depression, records indicated the ongoing use of an antidepressant without any attempt at GDR or documentation that a reduction was clinically contraindicated. The medication regimen review did not include a rationale for continuing the current dose, and the interim DON confirmed that no GDR was attempted and no rationale was documented. These findings demonstrate lapses in the facility's processes for monitoring and documenting the use of psychotropic medications.
Inaccurate MDS Assessments and Incomplete Functional Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident with a documented history of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and sleep terror, the MDS assessment incorrectly indicated that the resident was not considered by the state PASRR Level II process to have a serious mental illness, despite documentation to the contrary. This inaccuracy was confirmed by the MDS coordinator during an interview. Another resident's annual MDS assessment had section GG, which evaluates functional abilities and goals, marked as not assessed. The MDS coordinator stated that this section was dashed out because staff were not available at the time to perform the assessment. The RAI manual specifies that section GG is intended to capture important information about a resident's functional status, including self-care and mobility activities. These findings were based on medical record review, staff interviews, and reference to the MDS RAI manual.
Failure to Document and Act on Monthly Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly drug regimen reviews, including the identification and reporting of medication irregularities, for one of five sampled residents. Medical record review and examination of the interim DON's pharmacist monthly medication review binder revealed no evidence that the pharmacist had conducted or documented monthly medication reviews or made recommendations for the months of March, April, May, or June 2025. The resident involved had a diagnosis of schizophrenia and was receiving antipsychotic, antianxiety, and antidepressant medications during the review period. Staff interviews confirmed the absence of required documentation in the resident's record and the facility's binder.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to maintain a system for documenting that residents were provided education regarding the benefits and potential side effects of pneumococcal and influenza vaccines, as well as documentation of consent or refusal for immunization. In the case reviewed, a resident was admitted and subsequently declined both the influenza and pneumococcal vaccines. However, the medical record did not contain evidence that the resident was educated on the benefits and risks of these vaccines, nor was there a copy of the consent or declination form maintained in the record. Interviews with the interim DON and ADON confirmed that no further documentation was available to support that the required education or consent/refusal process had occurred. Review of the facility's policies for both influenza and pneumococcal vaccines indicated that education and documentation of consent or refusal should be provided and maintained in the resident's medical record, but this was not followed in the instance reviewed.
Failure to Issue Accurate Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to properly issue the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) for two out of three sampled residents. For one resident, the NOMNC form indicated the last covered day for Medicare Part A services, but the form was only signed by the social services director with a note that verbal notice was received by the resident's representative. Additionally, the SNF ABN form for this resident was found to have another resident's name at the top, and it did not include the required reason why Medicare may not pay or the estimated cost of the services. The form was also signed by the social services director with a note of verbal receipt by the representative. For another resident, the SNF ABN form indicated the last covered day for Medicare Part A services, but again failed to include the reason Medicare may not pay or the estimated cost. Interviews with the interim DON and MDS coordinator confirmed that the NOMNC and ABN forms were inaccurate. Review of facility policy showed that residents are to be informed in writing in advance when changes to their Medicare coverage occur, including the reasons for non-coverage and potential financial liability, but this process was not followed as required.
Failure to Implement and Monitor Wound Care Results in Harm
Penalty
Summary
The facility failed to implement and monitor wound care treatment as ordered for a resident with multiple non-pressure wounds on the lower extremities. The resident, who was cognitively intact and had a history of congestive heart failure, hypertension, renal insufficiency, benign prostatic hyperplasia, and encephalopathy, developed several stage 2 non-pressure ulcers on both legs and toes. Despite physician orders for specific wound care treatments, documentation showed inconsistent and incomplete implementation of these treatments, with missed dressing changes and lack of evidence for as-needed care or refusals. Wound assessments and measurements were not consistently performed or documented, and new wounds were not always identified or measured in the medical record. Wound photographs and medical record reviews revealed that the resident's wounds worsened over time, with increased size, drainage, discoloration, and additional open areas developing. The treatment administration record indicated that wound care was not performed on certain dates, and some treatments were carried out by staff not qualified to assess or measure wounds. Interviews with staff confirmed that wound care was not always documented, and there was no oversight of the wound care program within the facility. The infection preventionist acknowledged the lack of monitoring and documentation for wound care and as-needed dressing changes. The resident was eventually transferred to the hospital in poor condition, with saturated dressings and wounds covered in feces. Hospital records documented that the resident had extensive wounds with sloughed skin, erythema, and signs of infection, leading to a diagnosis of sepsis and cellulitis likely secondary to the lower extremity wounds. The facility's failure to provide consistent wound care and monitoring, as well as the lack of oversight and documentation, resulted in actual harm to the resident.
Wound Care Provided Outside Scope of Practice by MA-C
Penalty
Summary
Nursing staff failed to ensure that wound care was provided within the appropriate scope of practice for two residents. Observations showed that a Medication Assistant-Certified (MA-C) performed wound care procedures, including the application of Vashe solution and xeroform, on open wounds. The MA-C did not perform wound measurements or assessments, stating that these tasks were reserved for nurses and were only completed by the wound team on specific days. Documentation revealed that wound care treatments for one resident were performed by a MA-C, and on some scheduled dates, treatments were not performed at all. Interviews with facility staff indicated uncertainty regarding the MA-C's authority to apply topical medications to wounds. The infection preventionist/staff development coordinator was unable to provide competencies for MA-Cs performing wound care and acknowledged that MA-Cs should not apply topical medications to wounds. Review of state nursing board advisory opinions confirmed that CNA IIs and MA-Cs are not permitted to apply medications, including topical agents, to wounds, and that wound care by CNA IIs is only allowed after assessment by a provider or RN. No evidence was provided to show that the MA-C's actions were within their legal scope of practice.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During wound care for a resident with open wounds on the left shin and toe, a medication aide-certified (MA-C) performed hand hygiene and donned gloves but did not wear a gown, despite a container of personal protective equipment, including gowns, being available near the resident's bed. The infection preventionist/staff development coordinator confirmed that enhanced barrier precautions, which require both gloves and gowns, should be used for all residents with wounds, and that this resident was on such precautions. Review of the facility's policy also indicated that enhanced barrier precautions, including the use of gowns, are required for residents with wounds, regardless of known infection or colonization status.
Failure to Administer Medication as Ordered Upon Resident Readmission
Penalty
Summary
A resident with multiple complex diagnoses, including infrarenal abdominal aortic aneurysm, acute kidney failure, atherosclerosis of the renal artery, anxiety disorder, congenital renal artery stenosis, and cerebral infarction, was re-admitted to the facility from the hospital. Upon review, it was found that the resident did not receive their prescribed dose of Nifedipine ER 30 mg at bedtime as ordered by the physician. The medication was not available upon the resident's return, and the dose was not administered until the following morning, as confirmed by the resident, their representative, and the physician's note. The Medication Administration Record (MAR) indicated the medication was not provided at the scheduled time, and there was no documentation to confirm the medication was obtained from the stat lock or administered as required. Interviews with facility staff revealed that the expectation was to obtain unavailable medications either from a local pharmacy or from the stat lock if the primary pharmacy could not supply them in time. However, the DON was unable to provide evidence that the medication was accessed from the stat lock or given to the resident. The physician was not notified of the missed dose, and the facility's policy required medications to be administered as ordered and documented in the MAR. The failure to provide the medication as prescribed and to document its administration resulted in the identified deficiency.
Resident's Visitation Rights Restricted Without Just Cause
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing when a no trespass order was issued against the resident's friend, preventing further visits. The incident began when the resident's friend witnessed an altercation in which another resident accused the resident of hitting them. The friend, who observed the event, verbally defended the resident and addressed the other resident directly. Following this, the facility reported the incident, noting that the visitor had verbally expressed frustration but had left before law enforcement arrived. The police later informed the friend that they were no longer permitted to visit the facility. Interviews with the administrator revealed that the decision to issue the no trespass order was based on the friend's disrespectful behavior, which did not rise to the level of verbal abuse or a pattern of problematic conduct. The administrator also confirmed that no less restrictive measures, such as supervised or limited visitation, were attempted prior to the ban. Review of facility policy indicated that visitation restrictions are only to be applied in cases of abuse, exploitation, or coercion, and not for disrespectful behavior. The policy did not support the action taken in this case.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's physician of significant changes in the resident's condition. The resident, who had a history of heart failure and diabetes mellitus, was admitted without any wounds or edema. However, subsequent skilled nursing evaluations documented the development of pitting edema in both lower legs over several days, and a wound evaluation later identified a venous wound on the left foot that required treatment with Unna boots. Despite these new findings, there was no evidence in the medical record that the resident's physician was notified about the new onset of edema or the venous wound. Interviews with a family member and the DON confirmed that the physician was not informed of these changes. The family member was unaware of any physician notification and stated that only the wound care team was informed. The DON clarified that while a physician rounded with the wound care team, it was not the resident's primary physician, and there was uncertainty about whether communication occurred between physicians. Additionally, there were no physician orders for the wound care provided, and the facility could not provide documentation of physician notification regarding the resident's new conditions.
Failure to Provide Wound Care per Physician Orders and Standards
Penalty
Summary
The facility failed to provide wound care in accordance with physician orders and professional standards for two residents with non-pressure-related wounds. For one resident with heart failure and diabetes, a venous wound developed on the left foot and was treated by a physical therapist with Unna boots, Coban, and later with wound cleanser, zinc, and bordered gauze. There was no evidence in the medical record that the resident's physician was notified of the wound or that physician orders were obtained for the wound care. The family was not aware of physician notification, and the DON confirmed that wound care was recommended by the physical therapist without physician involvement or orders. For another resident with a surgical wound from a right thumb amputation, the orthopedic follow-up recommended daily dressing changes. However, there were no physician orders for these dressing changes, nor was there documentation that the dressing changes were completed. The DON confirmed that the facility had not seen the orthopedic note until later and that the resident occasionally requested a band-aid from staff. The facility's policy required wound treatments to be provided per physician orders and for the physician to be notified in the absence of such orders, but this was not followed in these cases.
Medication Administration Error: Unnecessary Drug Use Due to Transcription Mistake
Penalty
Summary
A deficiency occurred when a resident was administered Tramadol without adequate indication for its use. The resident, who had a history of falls and unspecified pain but did not report pain during the assessment period, was admitted with an order for Tramadol 50 mg every 6 hours as needed (PRN) for pain. However, the order was incorrectly transcribed as a routine order for every 6 hours, rather than PRN, and remained in place for approximately 11 days. During this period, the resident received Tramadol seven times when their pain level was documented as zero. Family members noticed the resident appeared 'out of it' and requested that Tramadol not be given as frequently, preferring scheduled Tylenol Arthritis and Tramadol only at bedtime. The DON later confirmed the transcription error regarding the medication order.
Failure to Address Missing Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident with moderately impaired cognition and Alzheimer's dementia. The resident's family repeatedly voiced concerns about missing hearing aids during care plan meetings over a two-year period, but no grievance form was filled out, and no action was taken to locate or replace the hearing aids. The facility's grievance logs showed no documentation related to the missing hearing aids, and the care plan intervention to ensure hearing aids were in place was not followed. Interviews with the resident's representative revealed that the family was unaware of the need to fill out a grievance form and had verbally informed staff of the issue multiple times. The administrator and social services director were unaware of the missing hearing aids, and the protocol for handling grievances was not followed. Additionally, there was no inventory of the resident's belongings from admission, and staff interviews indicated that the resident had not been seen wearing hearing aids for several years. The facility's policy required staff to record grievances and take immediate action, but this was not done in this case.
Failure to Implement Comprehensive Care Plan for Resident with Hearing Impairment
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with moderately impaired cognition and Alzheimer's dementia. The resident's quarterly MDS assessment indicated a BIMS score of 10 out of 15, and the social services assessment noted highly impaired hearing. The care plan, last updated on 1/12/25, included an intervention to ensure hearing aids were in place due to difficulty hearing related to advanced age. However, medical records and ADL tasks from 12/16/24 to 1/14/24 indicated the resident did not own hearing aids. An observation on 1/15/25 confirmed the resident was not wearing hearing aids. A medication aide, who had provided care to the resident for six years, stated he had never seen the resident wear hearing aids, and the administrator could not find an inventory of the resident's belongings upon admission, confirming the resident had not been wearing hearing aids.
Sanitation and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as observed during a survey. A non-working handwashing sink in the dishwashing room had a disconnected drain pipe, leading to water being collected in a bucket underneath. The floor under the dishwasher was found to be dirty with grime, food particles, and hard water build-up. The cleaning schedule posted in the kitchen lacked initials indicating cleaning had been performed since a specific date. Interviews with kitchen staff revealed ongoing issues with broken faucets and a lack of adherence to the cleaning schedule. The facility's dishwasher was not operating at the required temperatures for effective sanitization. Observations showed that the Ecolab ES-4000 dishwasher's water temperature started at 110 degrees Fahrenheit and only occasionally reached the required 120 degrees Fahrenheit after multiple runs. The dishwasher temperature logs for March and May 2024 indicated that the wash water temperature reached the required level only a few times out of numerous opportunities. Interviews with dietary aides confirmed awareness of the low temperatures, and it was noted that both facility maintenance staff and an Ecolab technician were informed of the issue. The facility's policies and procedures, as well as the 2022 FDA Food Code, emphasize the importance of maintaining proper plumbing and dishwasher temperatures to prevent potential health hazards. The facility's failure to adhere to these standards, as evidenced by the broken plumbing and inadequate dishwasher temperatures, poses a risk of contamination and does not comply with professional standards for food safety and sanitation.
Facility Lacks On-Site Licensed Administrator
Penalty
Summary
The facility failed to ensure that a licensed administrator was responsible for the management of the facility. The census was 74. The facility administrator, interviewed on June 13, 2024, confirmed that she did not reside in the same town as the facility and communicated with the facility via email and phone calls. She was unable to work on-premise due to employment with another agency in her town and had never visited the facility. Observations from June 10 to June 13, 2024, showed that the identified facility administrator was not present on the premises during the survey. Instead, an unlicensed administrator in training occupied the administrator's office and performed management functions. Interviews with the Director of Nursing (DON) and the administrator in training on June 10, 2024, revealed that the facility administrator did not work on-site and had weekly calls with the facility. The Chief Operating Officer confirmed on June 13, 2024, that the previous administrator went on leave on May 20, 2024, and was expected to return on June 24, 2024. The current licensed administrator was employed at another agency in her town.
Failure to Maintain Dishwasher Temperature
Penalty
Summary
The facility failed to ensure that essential equipment, specifically the Ecolab ES-4000 chemical sanitizing low-temperature dishwasher, was in safe operating condition in the kitchen. Observations and interviews revealed that the dishwasher's water temperature was consistently below the manufacturer's recommended minimum of 120 degrees Fahrenheit. On multiple occasions, dietary aides reported that the water temperature started at 110 degrees Fahrenheit and only occasionally reached 120 degrees Fahrenheit after several runs. The facility's dishwasher temperature logs for March and May 2024 showed that the required temperature was met only a few times out of numerous opportunities. The facility's dishwasher temperature policy mandates adherence to the manufacturer's instructions, which specify a wash temperature of 120 degrees Fahrenheit. However, the facility did not consistently meet this requirement. The 2022 FDA Food Code emphasizes the importance of maintaining specific parameters, such as temperature, to ensure effective sanitization. The report indicates that both facility maintenance and the Ecolab technician were aware of the low water temperatures, yet the issue persisted, leading to a deficiency in maintaining essential equipment in safe operating condition.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to infection prevention guidelines during meal service in the sunflower dining area. Resident #36, who has short-term and long-term memory impairment, diabetes mellitus, non-Alzheimer's dementia, and dysphagia, required assistance with eating. During an observation, a dietary staff member was seen passing meal trays while an unidentified resident attempted to reposition Resident #36 to a table. Resident #36 began piling items on their plate and was not consuming any food. Other residents, #55 and #61, attempted to provide verbal cues and physical assistance to Resident #36, including picking up food with bare hands and trying to help them eat and drink. The dietary staff member did not intervene, and no facility staff provided the necessary assistance or cues as outlined in the resident's care plan. Interviews with the Director of Nursing (DON) and the infection preventionist confirmed that staff should follow the care plan for eating assistance and that it is inappropriate for residents to touch another resident's food. The infection preventionist highlighted the risk of contamination from residents' hands. The facility's policy on Activities of Daily Living states that residents unable to carry out daily activities should receive necessary services to maintain good nutrition and hygiene, which was not adhered to in this instance.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the Notice of Medicare Provider Non-Coverage (NOMNC) and the Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) forms to a resident or their representative in a timely manner. This deficiency was identified during a review of beneficiary protection notice information, staff interviews, and policy and procedure reviews. Specifically, a resident with a Medicare Part A stay beginning on December 29, 2023, and ending on March 12, 2024, did not have evidence of receiving the required SNF ABN or NOMNC forms at the end of their Part A services. An interview with the business office manager confirmed the notices should have been issued, but there was no evidence to support that they were provided. The facility's policy on Advance Beneficiary Notice, reviewed on June 13, 2024, mandates the use of the SNF ABN form CMS-10055 for Part A items and services and the issuance of the NOMNC form CMS-10123 when Medicare-covered services are ending. This policy aims to inform residents about how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). However, the facility did not adhere to this policy for the resident in question.
Failure to Conduct PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level II was conducted for a resident with a qualifying diagnosis. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, was diagnosed with anxiety disorder and post-traumatic stress disorder. A PASARR Level I assessment had been completed, indicating the need for a Level II determination if the resident's stay exceeded 120 days. However, there was no evidence of a PASARR Level II assessment in the resident's medical record. Interviews with the Director of Nursing (DON) revealed that social services were responsible for PASARR assessments, but the facility lacked social services staff at the time and did not have a PASARR policy in place.
Failure to Assist Resident with Dining Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically during dining, for a resident with memory impairments and multiple diagnoses, including diabetes mellitus, non-Alzheimer's dementia, and dysphagia. The resident required set-up or clean-up assistance with eating, as outlined in their care plan. However, during an observation in the dining room, the resident was seen piling items on their plate and banging the table without consuming any food. Other residents attempted to assist by providing verbal cues and physically helping the resident to eat and drink, but no facility staff intervened to provide the required assistance or cues. The dietary staff member present did not offer any help, and the Director of Nursing (DON), who was also in the dining room, did not provide assistance or cues to the resident. Interviews with the DON and the infection preventionist confirmed that it was inappropriate for other residents to assist with eating and that staff should follow the care plan for eating assistance. The facility's policies on activities of daily living and meal supervision emphasized the need for individualized care plans and adequate supervision during mealtime, which were not adhered to in this instance.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that expired medications were not available for use in one of the three medication storage units, specifically the 200-hall medication cart. During an observation, it was found that an insulin Aspart flex pen and a Basaglar insulin pen were present without expiration dates. An interview with an RN confirmed that these medications were intended for resident use and should have been dated when removed from the refrigerator. The Director of Nursing (DON) stated that it was expected for staff to label insulin pens with an open date, and acknowledged that the observed pens were not labeled with an open or expiration date. The facility's policy on medication administration required identifying expiration dates and notifying the nurse manager if expired. Additionally, the insulin pen policy mandated clear labeling with the resident's name, physician's name, date dispensed, and expiration date, and specified disposal after 28 days or per manufacturer's recommendation. Manufacturer guidelines confirmed that both insulin types should be discarded after 28 days.
Inaccurate Daily Staff Postings
Penalty
Summary
The facility failed to provide accurate data on the daily staff postings for a two-week look-back period. On 6/10/24, an observation of the posted nurse staffing showed that the census was 74, and the staffing data for LPNs and MA-Cs was combined on one line of the posting. A review of the daily staff postings from 6/11/24 confirmed that the LPN and MA-Cs staffing data continued to be combined on one line. An interview with the Director of Nursing (DON) on 6/12/24 confirmed that the daily staff postings incorrectly combined the LPN/LVNs and MA-Cs, and she acknowledged that they should have been counted separately.
Unlicensed Nursing Care Provided by DON
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) was licensed by the State of Wyoming before providing nursing care to residents. The former DON was hired without a valid Wyoming nursing license and was supposed to perform only administrative duties until obtaining the license. However, the former DON engaged in nursing care activities, including completing assessments and documentation for five residents. These activities included completing an Abnormal Involuntary Movement Scale assessment, an Alert Charting Note, a Braden Scale assessment, a medication reconciliation form, and adding medications to the electronic medical record. The facility was aware of the licensing issue, as confirmed by an interview with the chief of operations, who stated that the former DON was only to perform administrative tasks until licensed. Despite this, the former DON provided nursing care without the necessary licensure. The former DON was eventually granted a Wyoming nursing license but was terminated shortly after. Interviews with the human resource director and the nursing home administrator confirmed the timeline of events and the provision of nursing care without a license.
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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