Shepherd Of The Valley Rehabilitation And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Casper, Wyoming.
- Location
- 60 Magnolia St, Casper, Wyoming 82604
- CMS Provider Number
- 535042
- Inspections on file
- 39
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Shepherd Of The Valley Rehabilitation And Wellness during CMS and state inspections, most recent first.
A resident who was cognitively intact but dependent for transfers and required a full body mechanical lift was being moved from bed to a recliner by two aides when a sling shoulder strap detached from the lift, causing a fall. Staff and witness statements confirmed that the lift in use lacked safety clips on the spreader bar, despite manufacturer instructions requiring safety clips to be present and properly used. The DON acknowledged that safety clips had been removed from the lifts because they were viewed as ineffective. The resident sustained a cervical fracture and subsequently went into cardiac arrest with death pronounced the same day, and the situation was determined to be immediate jeopardy.
Surveyors found that staff failed to follow infection prevention practices for urinal use and maintenance for three residents. One resident with severe cognitive impairment and multiple comorbidities had a urinal containing urine with visible discoloration and dried residue that was not dated. Two urinals for another resident were still in place more than a month after the date written on them, and a third resident’s urinal showed staining and was not labeled with a date. CNAs reported that urinals were typically changed monthly and as needed, while an LPN and the infection preventionist stated that soiled urinals should be discarded and replaced, and that urinals should be labeled and replaced at least monthly. The DON confirmed urinals should be replaced when visibly soiled and acknowledged there were no written facility policies governing urinal use.
A resident with severe cognitive impairment and a history of hip fracture, stroke, anxiety, and depression had a care plan indicating a preference for twice-weekly baths and a need for maximum assist with bathing. Bathing records showed the resident initially received showers twice weekly, but the frequency was later reduced to once weekly after the resident moved to another unit, without documented reassessment of bathing preferences. The administrator acknowledged that preferences should have been reassessed after the move, while bath aides reported that bathing schedules are generally maintained and that they would ask new residents about their preferences. The current bathing schedule and medical record confirmed the resident was only scheduled for weekly showers, with no documented reevaluation or change in the care plan to support the reduced frequency.
A resident with moderately impaired cognition, dementia, depression, cancer, identified fall risk, and risk for skin breakdown was care planned to have the call light kept within reach, but surveyors observed the resident seated in a recliner with the call light out of reach on multiple occasions. The resident did not know where the call light was, had a wet brief, and could not request assistance, which was also confirmed by the resident’s representative, who noted the resident was covered with a blanket and not wearing pants underneath. A guest ultimately activated the call light, after which a CNA responded and removed soiled linens. The DON stated staff are expected to ensure residents have access to the call light and needed items when left alone, while the NHA acknowledged there was no facility policy on call light use.
A resident with severe cognitive impairment and wandering behaviors entered another resident's room and was physically struck in the nose, resulting in a bloody nose. The resident who struck admitted to the action, and the incident was confirmed by staff and the DON. This event demonstrates a failure to protect a resident from physical abuse by another resident.
Two residents with surgical wounds experienced deficiencies in physician notification and timely implementation of treatment orders. One resident suffered actual harm and required additional surgery after the facility discontinued a wound vac without notifying the orthopedic surgeon. Another resident experienced a delay in wound care and antibiotic therapy due to failure to update physician orders, with the physician not notified of the delay. The facility did not follow its own policy for physician notification and timely care.
Three residents experienced deficiencies in care, including delayed wound assessment and treatment, failure to promptly implement physician orders for wound care and antibiotics, and inadequate neurological monitoring after a fall. One resident was hospitalized for sepsis after a wound worsened without timely intervention or family notification, another had a delay in starting prescribed wound care and antibiotics, and a third did not receive required neuro checks after a fall resulting in a nasal fracture.
A resident with a surgical wound and infection did not receive wound vac care as ordered by the surgeon. The wound vac was discontinued by facility staff without notifying the surgeon, leading to wound deterioration and the need for additional surgical intervention. Documentation showed improper wound vac application and lack of timely communication with the surgical team.
The facility failed to meet the activity needs of four residents, who expressed desires for specific activities but were not adequately informed or engaged. Residents participated minimally in independent activities, with limited group activity involvement due to staffing shortages and unappealing options.
The facility experienced staffing shortages, leading to unmet care needs and incomplete restorative programs for residents. Interviews revealed high CNA turnover and delayed responses to call lights. Discrepancies in bathing records were found, with showers documented by the DON not supported by bath schedule logs. The lack of restorative nursing was due to staff being reassigned to cover open shifts, and the East Station Bath Schedule logs were not part of official records.
The facility failed to identify and monitor target symptoms for residents receiving psychotropic medications. A resident with severe cognitive impairment and multiple diagnoses was on several psychotropic drugs without evidence of monitoring for effectiveness. This issue was also found in other residents with similar conditions, indicating a pattern of non-compliance with the facility's policy on psychotropic drug use.
The facility failed to label and date insulin pens in two medication storage areas. Observations revealed several opened insulin pens without dates. Interviews with an RN and the DON confirmed the requirement for labeling opened insulin pens. The facility's policy mandates dating multi-dose vials upon opening and discarding them within 28 days unless specified otherwise.
The facility failed to accurately document bathing records for three residents, leading to discrepancies between initial and updated records. Interviews revealed that the system was updated with information from bath schedule logs after records were requested, and the responsible staff member was no longer employed. The administrator confirmed that these logs were not part of official records, highlighting a deficiency in documentation practices.
The facility failed to provide consistent restorative nursing care to two residents, leading to a decline in their ability to perform activities of daily living. One resident, who was cognitively intact, reported a decline in mobility due to the lack of restorative care, while another resident with severe cognitive impairment experienced inconsistent delivery of restorative programs. The deficiency was attributed to staffing shortages, with restorative aides being reassigned to cover open shifts.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastric tube. An RN was observed providing high-contact care without wearing a gown, despite EBP signage indicating the need for gowns and gloves. Staff interviews revealed a lack of awareness about EBP requirements, and the facility's policy, which mandates gowns and gloves for high-contact care, was not adhered to.
A resident with severely impaired cognitive skills and non-Alzheimer's dementia was physically abused by another resident with moderate impairment and a history of violent comments. The altercation resulted in the victim sustaining a nasal bone fracture after being punched in the face. The incident was witnessed by a CNA student, highlighting a failure to enforce the facility's abuse prevention policy.
A resident with moderate cognitive impairment and a history of making violent comments was involved in two physical altercations with another resident, resulting in injury. The care plan was updated to include distraction techniques but failed to address the resident's physical aggression, as confirmed by the DON.
A resident with acute respiratory symptoms was not tested for COVID-19 despite exhibiting symptoms and the presence of COVID-19 in the facility. Staff interviews revealed a failure to adhere to infection prevention protocols, as the resident's representative had to bring a test from outside to confirm the infection. The facility's policy required immediate testing for respiratory symptoms, but this was not followed.
A resident with moderate cognitive impairment and enteritis experienced multiple episodes of vomiting and dehydration, but the facility failed to notify the physician or reassess the condition promptly. The resident was transported to the hospital via facility van without healthcare staff, leading to a collapse and death in the emergency room waiting area.
Failure to Use Required Safety Clips on Mechanical Lift Resulting in Resident Fall and Cervical Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe staff practices and safe working conditions when using a full body mechanical lift for a resident who was dependent for transfers. The resident had a BIMS score of 15/15, indicating intact cognition, and medical diagnoses including morbid obesity, heart failure, and renal insufficiency, and required a full body mechanical lift for transfers. On the day of the incident, the resident was being transferred from bed to a recliner by two aides using a full body mechanical lift when the left shoulder strap of the sling came loose from the lift, causing the resident to fall to the floor. Witness documentation and staff interviews indicated the resident was found face down on the floor with legs over one leg of the lift, with all but one sling strap still attached. The incident report concluded that the resident had a tendency to shift weight and reposition while in the sling and that the sling strap likely came up on one side and then came off the lift. Further investigation showed that the mechanical lift in use at the time of the fall did not have safety clips on the spreader bar, as confirmed by both aides involved in the transfer and by an RN who responded to the incident. The RN identified the specific model used and confirmed that safety clips were not present at the time of the fall. A laminated Quick Reference Guide attached to the same model of lift, and the manufacturer’s Quick Reference Guide provided by the DON, both instructed staff to ensure safety clips on the spreader bar are in position after the sling is applied and to check that safety clips are present and used properly. The DON reported that safety clips had been removed at some point because they would come off and were considered ineffective. Based on the failure to follow manufacturer instructions for use of safety clips on the mechanical lift, the resident fell from the lift and sustained a mildly displaced fracture of the left C2 transverse process with extension into the C2 vertebral body, and later went into cardiac arrest with death pronounced the same day. This failure was determined to constitute immediate jeopardy.
Failure to Implement Proper Urinal Cleaning and Replacement Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the use and maintenance of urinals for three sampled residents. One resident with severe cognitive impairment, cancer, depression, non-Alzheimer’s dementia, lower extremity impairment, who was wheelchair bound and required substantial to maximal assistance with toileting hygiene, was observed with a urinal hanging from a trash can next to a recliner that contained approximately 100 milliliters of amber-colored urine. The urinal showed dark blue and black discoloration inside and a dried yellow substance around the opening, and it was not labeled with a date. A CNA stated that residents’ urinals were emptied every two hours and replaced monthly, and later confirmed that this urinal was not dated and appeared discolored and soiled. Additional observations showed two empty urinals dated more than a month earlier hanging from a trash can next to another resident’s bed, with a CNA confirming they had not been replaced after one month of use. Another resident’s urinal was observed hanging from a nightstand, empty but with yellow, amber, and dark blue staining inside, and it was not dated; a CNA confirmed the urinal appeared soiled and undated and reported that urinals were changed monthly and as needed. An LPN stated staff were expected to discard soiled urinals and replace them when they appeared soiled. The infection preventionist reported that staff were expected to label urinals and replace them at least monthly or when visibly soiled, and the DON confirmed urinals should have been replaced when visibly soiled and acknowledged there were no facility policies regarding urinals.
Failure to Maintain Resident’s Preferred Bathing Frequency After Unit Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s activities of daily living, specifically bathing, according to the resident’s assessed needs and stated preferences. A quarterly MDS dated 1/23/26 for resident #11 showed a BIMS score of 3/15, indicating severe cognitive impairment, and diagnoses including a history of hip fracture, stroke, anxiety, and depression. The care plan dated 10/24/25 documented that the resident preferred bathing twice a week and required maximum assistance with bathing and showering. Review of the bathing record from 12/10/25 through 1/6/25 showed the resident received showers twice weekly until 1/14/26, when the frequency was reduced to once weekly. The administrator stated on 3/12/26 that the resident had moved from another unit on 12/30/25 and that shower preferences should have been reassessed and had changed, but no evidence of such reassessment was found. Bath aide interviews indicated that bathing schedules were expected to be maintained when residents moved units and that staff would typically ask new residents about their bathing preferences. The current bathing schedule and medical record confirmed the resident was scheduled for and receiving only weekly showers, with no documented reevaluation of preferences or change in the bathing schedule.
Failure to Ensure Call Light Accessibility and Supervision for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent accidents for one resident with moderately impaired cognition and multiple diagnoses, including non-Alzheimer’s dementia, depression, and cancer. The admission MDS showed a BIMS score of 12/15 and the care plan, last revised on 11/19/25, identified the resident as a moderate fall risk related to confusion, gait and balance problems, and psychoactive drug use, with an intervention initiated on 11/25/24 to ensure the call light was within reach. A Braden Scale assessment on 1/2/26 scored the resident at 16/23, indicating risk for skin breakdown. Despite these identified needs and care plan interventions, observations on 1/28/26 at 9:55 AM and 10:35 AM showed the resident seated in a recliner at the foot of the bed with the call light located at the head of the bed and not within reach, while the resident’s lower body was covered with a blanket. Further observations and interviews on 1/28/26 showed the resident did not know where the call light was and stated it “should be around here somewhere.” At 11:33 AM, the resident’s brief was confirmed to be wet, and the resident reported being unable to request assistance because the call light was not accessible. The resident’s representative also observed that the resident’s brief was wet, the resident was covered with a blanket without pants underneath, and the call light had not been within reach to request help. At 11:48 AM, the call light was activated by the resident’s guest, and at 11:53 AM a CNA answered the call light, closed the door, left the room, returned with a clean blanket, and exited at 12:04 PM with two bags of soiled linens. The DON later confirmed that staff are expected, when leaving a resident alone, to set the resident up with the call light and other needs and perform hand hygiene, and the NHA reported that the facility did not have a policy on call light use.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment, wandering behaviors, and diagnoses including encephalopathy and agitation was involved in an incident where they entered another resident's room in the memory care unit. The resident whose room was entered asked the wandering resident to leave, and when this did not occur, physically struck the wandering resident in the nose, resulting in a bloody nose. The incident was documented in the facility's records, and the resident who was struck was able to stop the bleeding on their own. Interviews confirmed that the resident who struck the other admitted to the action, and the event was reported to the affected resident's representative. Staff interviews revealed that the assessment following the altercation confirmed the physical injury and emotional impact on the resident who was struck. The incident was also confirmed by the DON, who acknowledged the physical altercation and resulting injury. The deficiency centers on the facility's failure to protect a resident from physical abuse by another resident, as required by regulations.
Failure to Notify Physicians of Changes in Condition and Treatment Orders for Residents with Surgical Wounds
Penalty
Summary
The facility failed to notify physicians of changes in condition or treatment for two residents with surgical wounds, resulting in actual harm to one resident. For the first resident, who was cognitively intact and had a complex right elbow surgical wound with infection, the wound vac order was discontinued by the facility's wound nurse without notifying the orthopedic surgeon. The resident subsequently presented to the clinic without the wound vac in place, leading to exposure and deterioration of the triceps tendon, and required additional surgical intervention. Documentation showed that the facility's PA-C and nursing staff communicated with the clinic only after the wound had worsened, and the orthopedic surgeon confirmed that the lack of notification and discontinuation of the wound vac led to the need for further surgery. For the second resident, who had moderate cognitive impairment and a surgical wound on the right tibia, there was a delay in initiating physician-ordered wound care and antibiotic therapy. Orders for wound care and Keflex were written and noted in the medical record, but the treatments were not started until several days later. The DON confirmed that the nurse failed to update the physician orders in a timely manner, and the orthopedic surgeon was not notified of the delay in starting the prescribed treatments. A review of the facility's skin integrity policy indicated that licensed nurses are required to notify physicians and resident representatives of changes in wound condition or new treatment orders. The policy also requires weekly wound evaluations and prompt notification if a wound fails to improve or deteriorates. In both cases, the facility did not follow its own policy regarding physician notification and timely implementation of treatment orders, resulting in harm and delayed care for the affected residents.
Failure to Provide Timely and Appropriate Care, Wound Management, and Post-Fall Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. One cognitively intact resident with diabetes, neuropathy, and renal insufficiency was at risk for pressure ulcers and developed a right buttock wound with increased depth, yellow/green slough, and foul odor. Despite documentation of these changes, there was a lack of timely follow-up notes regarding the wound or possible infection for several days. The resident's family was not notified of the wound's severity until the resident was hospitalized for sepsis, and the representative reported that the resident should have been sent to the hospital sooner. Another resident with moderate cognitive impairment and a surgical wound had physician orders for wound care and antibiotics that were not implemented until five days after the orders were written. The delay was discovered by the facility, and the orthopedic surgeon was not notified of the delay in starting the prescribed treatments. This lapse resulted from the nurse's failure to update the physician orders in a timely manner. A third resident with severe cognitive impairment and a high risk for falls experienced an unwitnessed fall, after which only one neurological assessment was documented, despite facility protocol requiring more frequent checks. The resident later presented with bruising and an abrasion, and a CT scan revealed a nondisplaced acute nasal bone fracture. The DON was unable to account for the missing neurological assessment records, and the facility's policy for post-fall monitoring was not followed.
Failure to Follow Wound Vac Orders and Notify Surgeon Resulting in Harm
Penalty
Summary
A resident with a history of a right elbow fracture, surgical wound, and wound infection, including methicillin-resistant Staphylococcus aureus (MRSA), was admitted with a surgical wound requiring a wound vac as ordered by the orthopedic surgeon. The care plan included dressing changes as ordered, and the medication administration record indicated wound vac changes were scheduled three times weekly. However, the wound vac order was discontinued by the facility's provider after the wound nurse reported it was not applied, without notifying the orthopedic surgeon who had placed the original order. There was no evidence that the surgeon was consulted prior to discontinuing the wound vac. Subsequently, the resident was seen in clinic without the wound vac in place, and the triceps tendon was exposed and developing eschar, prompting a recommendation for further surgical intervention. Progress notes documented that the wound vac dressing was found improperly applied, causing the wound to be dry and the tendon frayed. The facility's provider and wound care nurse decided not to reapply the wound vac, and only after further communication with the clinic was a follow-up appointment and a skin graft consult arranged. The orthopedic surgeon confirmed that the resident required additional surgeries due to the facility's failure to follow the wound vac order and to notify the surgeon of changes.
Failure to Meet Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that activities met the interests and needs of four residents, as identified in the report. Resident #30, who was cognitively intact and had an amputation, expressed a desire to go outside and listen to music. However, the resident was unaware of available group activities and participated minimally in independent activities. The activity director acknowledged that activity aides should inform residents about activities upon admission. Resident #61, with moderate cognitive impairment and conditions including depression and phantom limb syndrome, expressed an interest in playing BINGO. Despite this, the resident's participation was limited to independent activities, with no recorded participation in BINGO. Similarly, Resident #41, who was cognitively intact and had multiple diagnoses, expressed a desire for more engaging activities. The resident participated in some independent activities but did not engage in group activities due to a lack of interest and the facility's limited ability to organize outings. Resident #22, also cognitively intact, had a range of interests including reading, music, and outdoor activities. However, the resident found the facility's activities unappealing and participated only in independent activities. The activity director noted that the facility had been understaffed, affecting their ability to offer diverse activities and outings. The director also mentioned efforts to hire additional staff and assess residents' activity preferences.
Staffing Shortages and Documentation Issues in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, affecting two of the five resident care units. Interviews with residents during a council meeting revealed issues such as high turnover of CNAs, delayed response to call lights, unmade beds, and untidy rooms. Several residents expressed concerns about the lack of staff, with one resident specifically mentioning a decline in their ability to transfer due to insufficient restorative nursing care. This resident's restorative nursing plan was not being followed because restorative staff were reassigned to cover open shifts. The documentation review revealed discrepancies in the bathing records for multiple residents. For instance, one resident's bathing record initially showed no showers for a period, but was later updated by the DON to reflect showers that were not documented in the East Station Bath Schedule logs. Similar inconsistencies were found in the records of other residents, where showers were documented by the DON but not supported by the bath schedule logs. These discrepancies indicate a lack of proper documentation and verification of care provided. Interviews with the DON, MDS coordinator, administrator, and regional clinical director confirmed that the lack of restorative nursing was due to staff being pulled to cover other duties. Additionally, the East Station Bath Schedule logs were not considered part of the official resident records, leading to further inconsistencies in documentation. The facility's failure to maintain accurate records and provide adequate staffing resulted in unmet care needs and incomplete restorative programs for residents.
Failure to Identify and Monitor Target Symptoms for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for five residents who were receiving psychotropic medications. Resident #45, with severe cognitive impairment and multiple diagnoses including non-Alzheimer's dementia and anxiety disorder, was receiving several psychotropic medications such as Ativan, bupropion, buspirone, sertraline, and trazadone. However, there was no evidence in the physician orders or care plan that the facility had identified or was monitoring specific target symptoms to evaluate the effectiveness of these medications. Similarly, Resident #96, who was cognitively intact but had diagnoses including non-Alzheimer's dementia and depression, was receiving quetiapine and sertraline. The facility again failed to identify or monitor specific target symptoms for these medications. This pattern was repeated with Resident #120, who had severe cognitive impairment and was receiving escitalopram, olanzapine, and divalproex, as well as Resident #72 and Resident #114, both of whom had severe cognitive impairments and were on various psychotropic medications without identified target symptoms. The facility's policy on psychotropic drugs, last updated in October 2022, states that the Interdisciplinary Team (IDT) should validate appropriate diagnoses of behavioral symptoms and evaluate the resident's medication regime to avoid duplicate drug therapy. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of target symptoms and monitoring for the effectiveness of psychotropic medications in the residents' care plans and physician orders.
Failure to Label and Date Insulin Pens
Penalty
Summary
The facility failed to properly label and date medications in two of six medication storage areas, specifically on the South Hall medication carts #1 and #2. During an observation, it was found that several insulin pens, including Lantus Solostar, Novolog Insulin Aspart, and Humalog, were opened but not dated. Interviews with a registered nurse (RN) and the Director of Nursing (DON) confirmed that insulin pens should be labeled with the date they were opened, and that nursing staff were responsible for labeling multidose medications with the resident's name and the date of opening. A review of the facility's policy on Medication Storage and Handling indicated that multi-dose vials should be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer.
Inaccurate Documentation of Bathing Records
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for three residents regarding their bathing schedules. Resident interviews and medical record reviews revealed discrepancies in the documentation of showers received. One resident reported not receiving showers consistently due to staffing issues, and the initial 30-day bathing record showed no showers documented before a certain date. However, an updated record later showed showers documented by the DON, which were not initially recorded. Similar discrepancies were found for two other residents, where the updated records showed showers that were not documented in the original records. Interviews with the DON and MDS coordinator revealed that the system was updated with information from bath schedule logs after the records were requested, and the staff member responsible for completing these logs was no longer employed at the facility. The administrator and regional clinical director confirmed that the bath schedule logs were not part of the official resident records, and bathing was expected to be documented in the resident records when it occurred. This lack of accurate documentation led to the deficiency identified by the surveyors.
Inadequate Restorative Nursing Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative nursing care to maintain the ability of residents to perform activities of daily living. Resident #22, who was cognitively intact and had functional limitations in range of motion, reported a decline in mobility and the need for a full body mechanical lift due to the lack of restorative care. Despite having an active restorative nursing plan, the resident's programs were inconsistently provided, with only a few sessions documented over several months. The resident expressed a desire to participate in restorative care but was informed that staffing shortages were preventing the implementation of the plan. Resident #100, who had severe cognitive impairment and no range of motion impairment, also experienced inconsistent delivery of restorative programs. The resident's scheduled activities were sporadically provided, with significant gaps between sessions. Interviews with the Director of Nursing and MDS coordinator confirmed that the lack of restorative nursing was due to restorative aides being reassigned to cover open shifts on the floor. The facility's policy indicated that residents at risk of functional decline should receive restorative care, but this was not adhered to in practice.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control procedures for a resident under Enhanced Barrier Precautions (EBP). During an observation, a stop sign indicating EBP was posted on the resident's room door, but the registered nurse (RN) did not adhere to the required precautions. The RN was observed wearing gloves but no gown while providing high-contact care, including removing a gastric tube dressing and assisting in repositioning the resident. The RN admitted that gowns were supposed to be worn for such care but were not available in the room at the time. Interviews with staff revealed a lack of awareness and understanding of the EBP requirements. A certified nursing assistant (CNA) stated she was unaware of the need to wear gowns until the day before the interview. The infection preventionists confirmed that EBP required gowns and gloves for high-contact care involving residents with medical devices like feeding tubes. The facility's policy on EBP, last revised in March, outlined the necessity of using gowns and gloves to prevent the transfer of multi-drug resistant organisms, but this was not followed in practice.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. Resident #1, who had severely impaired cognitive skills and a diagnosis of non-Alzheimer's dementia, was involved in an altercation with Resident #2. Resident #2, with a BIMS score indicating moderate impairment and a history of making violent comments, punched Resident #1 in the face after a confrontation in the hallway. This incident led to Resident #1 sustaining a nasal bone fracture and being taken to the hospital. The altercation occurred after Resident #1 approached Resident #2 and engaged in behavior that led to a physical confrontation. Despite Resident #2's history of making comments about past violence, the facility did not prevent the escalation that resulted in physical harm. The incident was witnessed by a CNA student, and the facility's policy on abuse, which defines physical abuse as including punching, was not effectively enforced to prevent the incident.
Failure to Address Physical Aggression in Resident Care Plan
Penalty
Summary
The facility failed to develop an individualized, comprehensive care plan for a resident with a history of traumatic brain injury and non-Alzheimer's dementia, who exhibited moderate cognitive impairment. The resident had a documented behavior problem of making comments about past violence towards women, although they would laugh and claim they would never act on these comments. Despite this, the care plan did not address potential or actual physical aggression, which became evident in two separate incidents involving physical altercations with another resident. In the first incident, the resident was involved in a shoving match with another resident after a verbal exchange, although no injuries were reported. In a subsequent incident, the resident punched the other resident in the face, resulting in a nasal bone fracture for the victim. The care plan was updated to include an intervention to engage the resident in conversation as a distraction when anxious, but it still failed to address the resident's physical aggression. The Director of Nursing confirmed that the care plan did not include measures for potential or actual physical aggression, highlighting a deficiency in the care planning process.
Failure to Implement Infection Prevention Protocols
Penalty
Summary
The facility failed to implement appropriate infection prevention interventions for a resident with acute respiratory symptoms. The resident, who was cognitively intact and had a history of atrial fibrillation, morbid obesity, diaphragmatic hernia, and obstructive sleep apnea, reported feeling unwell with symptoms such as weakness and a runny nose for several days before testing positive for COVID-19. Despite the resident's complaints and the presence of COVID-19 in the facility, staff did not test the resident for COVID-19, and the resident's representative had to bring a test from outside, which confirmed the infection. Interviews with staff revealed a lack of adherence to the facility's infection prevention protocols. RN #1 stated that nurses should follow up with the doctor and infection prevention staff regarding testing if residents exhibit COVID-19 symptoms. However, RN #2 admitted to not contacting the physician or performing COVID-19 testing, as the resident seemed to feel better. The facility's policy required immediate testing for residents showing respiratory symptoms, but this was not followed in the case of the resident. The infection preventionist confirmed that staff were expected to notify the infection prevention team and the physician for a COVID-19 order if a resident exhibited respiratory symptoms. The administrator and DON also indicated that nurses should monitor symptoms and notify the infection preventionist and doctor if symptoms worsen. Despite these protocols, the facility did not test the resident as required, leading to a deficiency in infection prevention and control.
Failure to Provide Timely Assessment and Treatment Leads to Resident Harm
Penalty
Summary
The facility failed to ensure timely assessment and treatment for a resident with a change of condition, resulting in actual harm. The resident, who had moderate cognitive impairment and required assistance with daily activities, was on antiplatelet therapy and had been prescribed anti-emetic medications for enteritis. Despite showing signs of dehydration and experiencing nausea and vomiting, the facility did not notify the physician promptly or reassess the resident's condition adequately. The resident experienced multiple episodes of vomiting and refused meals, yet there was no evidence of physician notification or reassessment of the resident's condition. The facility's staff did not consider the resident's condition critical, and the resident was transported to the hospital via the facility van without a healthcare staff member accompanying them. The resident's family had expressed concerns about the resident's condition, but the facility delayed contacting the physician and arranging for hospital transport. The resident was eventually taken to the emergency room after significant delays, during which time their condition worsened. The resident was left in the emergency department waiting area without facility staff, and subsequently collapsed and passed away. Interviews with facility staff revealed a lack of urgency in responding to the resident's condition and a failure to follow standard procedures for transporting unstable residents.
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.
Trusted data from CMS and state health departments
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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