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Inspection Reports for Edgewood Sierra Hills

WY, 82009

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Inspection Report Summary

The most recent inspection on November 20, 2025, found deficiencies related to infection control, immunization policies, food safety, quality improvement, and licensure survey posting. Earlier inspections also noted issues with timely reporting of incidents affecting resident health and safety, as confirmed by a complaint investigation on the same date that identified failures to report multiple incidents to the state survey agency. The main themes across deficiencies involved infection control practices, immunization compliance, food service sanitation, and quality improvement processes. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern of findings suggests ongoing challenges in regulatory compliance without clear improvement over time.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

106% worse than Wyoming average
Wyoming average: 3.4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2025
Unclassified
State average

Inspection Report

Re-Inspection
Census: 53 Deficiencies: 6 Date: Nov 20, 2025
Visit Reason
This is an onsite revisit survey conducted from 11/19/25 through 11/20/25 to verify correction of previous deficiencies cited on 6/5/25 at Sierra Hills Assisted Living Community.
Findings
The facility failed to meet several state rules and regulations related to infection control, immunization policies, food safety, quality improvement, and licensure survey posting. Deficiencies included failure to ensure tuberculosis testing for employees and residents, inadequate food temperature monitoring, and lack of a self-assessment survey for quality improvement. The census was 53 during the inspection.
Deficiencies (6)
Failed to ensure 3 of 5 sample employees were tested or screened for tuberculosis (TB) as appropriate on an annual basis.
Failed to implement influenza and pneumococcal immunization policy for 5 of 7 sample residents and failed to ensure residents were tested for tuberculosis prior to admission for 4 of 7 sample residents.
Failed to ensure food was prepared, stored, and distributed under sanitary conditions in 1 of 1 kitchen, related to temperature monitoring of food storage units.
Failed to maintain sanitary environment of the kitchen, including ice machine maintenance and dishwasher sanitization logs.
Failed to have an active quality improvement program including annual self-assessment survey and satisfaction survey.
Failed to post the state licensure survey results in a manner conducive for public view.
Report Facts
Census: 53 Temperature documentation days missing: 13 Temperature documentation days missing: 16 Employees tested for TB: 3 Residents reviewed for immunization: 7 Residents not tested for TB prior to admission: 4
Employees mentioned
NameTitleContext
David J. LovatoExecutive Director (Interim)Signed the report and plan of correction

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Nov 20, 2025
Visit Reason
A complaint survey was conducted by Healthcare Licensing and Surveys from 11/19/25 through 11/20/25, prompted by complaint intake LIC-26-011.
Complaint Details
The complaint investigation found that for 6 incidents reviewed, the facility did not report the incidents to the state survey agency as required. Specific incidents involving residents #1 through #5 were reviewed with dates ranging from 7/27/24 to 9/20/25. The clinical service director interview confirmed responsibility for completing investigations and submitting results to the state agency.
Findings
The facility failed to implement their policy and procedure for ensuring the investigation following an allegation of abuse, neglect, or incidents affecting resident health, welfare, or safety was reported to the Licensing Division in a timely manner for 6 of 6 incidents reviewed.
Deficiencies (1)
Failure to report incidents affecting the health, welfare, or safety of residents to the Licensing Division in a timely manner as required by policy and state regulations.
Report Facts
Incidents reviewed: 6 Incident dates: Jul 27, 2024 Incident dates: Sep 20, 2025 Completion date for corrective measures: Jan 20, 2026
Employees mentioned
NameTitleContext
Dino J. LovatoInterim Executive DirectorSigned plan of correction and corrective action acceptance
Jean YenniSigned acceptance of plan of correction
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