Inspection Report Summary
The most recent inspection on February 13, 2025, identified deficiencies related to the facility not having a registered nurse on duty for the required 8 consecutive hours and failing to provide specialized rehabilitative services to a resident. Earlier inspections showed a pattern of issues including inadequate supervision leading to a resident elopement, lapses in infection control practices, and a substantiated case of verbal and physical abuse by staff toward a resident. Other common themes involved care plan completeness, medication management, diet compliance, and staffing documentation. Complaint investigations were substantiated in several cases, including the abuse incident and the elopement, while most complaints involved staffing and care provision concerns. The facility’s deficiencies have persisted across multiple areas over time, with no clear pattern of overall improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Wyoming average
Wyoming average: 3.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
39 residents
Based on a February 2024 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to have a registered nurse on duty for 8 consecutive hours per day and failure to provide specialized rehabilitative services to a resident.
Complaint Details
The visit was complaint-related, focusing on the lack of an RN on duty for the required hours and failure to provide therapy services to a resident. The Director of Nursing and Director of Rehabilitation were unaware of the therapy orders for the resident.
Findings
The facility failed to ensure an RN was on duty for 8 consecutive hours on 2/8/25, with the RN working only 3.25 hours that day. Additionally, the facility failed to provide rehabilitative services to one resident (#150) despite physician orders, with staff unaware of the therapy orders.
Deficiencies (2)
Failed to have a registered nurse on duty for 8 consecutive hours per day, 7 days per week.
Failed to provide specialized rehabilitative services as required for a resident (#150).
Report Facts
Census: 533
Hours RN worked: 3.25
Sample residents: 8
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding RN duty hours and therapy services; confirmed RN did not work 8 hours and was unaware of therapy orders | |
| Director of Rehabilitation | Interviewed regarding therapy services; confirmed unawareness of therapy orders and that resident did not receive therapy |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an elopement incident involving a resident who was able to leave the facility without staff knowledge.
Complaint Details
The complaint investigation was substantiated as the resident eloped on 6/29/24 after a visitor let the resident out and gave a ride home without staff knowledge. The facility's wanderguard system was not properly tested prior to July 2024.
Findings
The facility failed to provide adequate supervision to prevent elopement for one resident and did not ensure the wanderguard system was tested per manufacturer's instructions. The resident was found outside the facility after a visitor let them out and gave them a ride home without staff knowledge. The facility lacked documentation of wanderguard function checks prior to July 2024.
Deficiencies (2)
Failed to provide adequate supervision to prevent elopement for 1 of 2 residents reviewed.
Failed to ensure the wanderguard system was tested per manufacturer's instructions.
Report Facts
Residents with wanderguard: 11
Date of elopement incident: Jun 29, 2024
Date of wanderguard order: Jun 17, 2024
Date of admission MDS assessment: Jun 24, 2024
Date of plan of correction implementation: Jul 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nurse in charge at the time of the elopement, interviewed regarding the incident. |
| LPN #1 | Licensed Practical Nurse | Responded to the front door alarm and interviewed about the elopement incident. |
Inspection Report
Routine
Census: 39
Deficiencies: 2
Date: Feb 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, including disinfection of reusable equipment and hand hygiene practices.
Findings
The facility failed to ensure appropriate disinfection of reusable equipment before contact with residents and failed to implement proper hand hygiene during meal observations. Observations showed multiple instances of equipment not being disinfected between residents and staff not performing hand hygiene as required.
Deficiencies (2)
Failure to ensure appropriate disinfection of reusable equipment before contact with residents.
Failure to implement appropriate hand hygiene practices during meal observations.
Report Facts
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #16 | Certified Nursing Assistant | Named in multiple observations related to failure to disinfect reusable equipment |
| CNA #20 | Certified Nursing Assistant | Named in observation related to failure to perform hand hygiene during meal assistance |
| Executive Director | Interviewed regarding expectations for staff hygiene and equipment cleaning | |
| Maintenance Supervisor | Observed failing to perform hand hygiene and proper infection control while serving residents |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 16, 2023
Visit Reason
The inspection was conducted due to allegations of verbal and physical abuse by staff against resident #10, as well as concerns about care plan completeness and infection control practices.
Complaint Details
The complaint investigation involved allegations that CNA #1 verbally threatened and physically forced resident #10 to eat during lunch, including pinching the resident's cheek and attempting to force food into the resident's mouth. The CNA was placed on leave pending investigation and subsequently terminated. Multiple staff and resident interviews confirmed the incident. The resident was assessed with no physical injury but reported feeling frightened. The facility implemented corrective measures including staff education and increased monitoring.
Findings
The facility failed to protect resident #10 from verbal and physical abuse by staff, resulting in the termination of the offending CNA. Additionally, the facility failed to develop comprehensive care plans for resident #39 related to wandering and elopement, and failed to ensure proper hand hygiene and glove use during perineal care for resident #19.
Deficiencies (3)
Failed to protect resident #10 from verbal and physical abuse by staff.
Failed to develop comprehensive care plans for resident #39, specifically for wandering and elopement.
Failed to ensure appropriate hand hygiene and glove use to prevent cross-contamination during perineal care for resident #19.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
BIMS score: 6
BIMS score: 7
BIMS score: 12
Incident date: Oct 21, 2023
Training dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal and physical abuse finding; terminated after investigation |
| RN #1 | Registered Nurse | Witnessed and reported abuse incident involving CNA #1 |
| CNA #2 | Certified Nursing Assistant | Witnessed abuse incident and reported it to charge nurse |
| CNA #3 | Certified Nursing Assistant | Heard abuse incident and resident yelling |
| CNA #4 | Certified Nursing Assistant | Named in infection control deficiency related to glove use |
| DON | Director of Nursing | Interviewed regarding abuse investigation, care planning, and infection control |
| ED | Executive Director | Interviewed regarding abuse investigation and resident safety |
| Divisional Director of Clinical Operations | Interviewed regarding abuse investigation and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
The inspection was conducted due to allegations of verbal and physical abuse by staff against resident #10 during a meal service.
Complaint Details
The complaint was substantiated. The investigation confirmed that CNA #1 verbally threatened and physically forced resident #10 to eat, including pinching the resident's cheek and attempting to force food into the resident's mouth. The CNA was terminated. Resident and staff interviews, incident reports, and progress notes supported the findings.
Findings
The facility failed to protect resident #10 from verbal and physical abuse by a CNA who forced the resident to eat and used profanities. The CNA was suspended and terminated following investigation. The resident was assessed with no physical injury but reported feeling frightened. Staff education and ongoing monitoring were implemented to prevent recurrence.
Deficiencies (1)
Failure to protect resident #10 from verbal and physical abuse by staff during meal service.
Report Facts
Residents Affected: 1
Dates of staff education: Staff education performed from 2023-10-25 through 2023-10-29
Date of incident: Incident occurred on 2023-10-21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal and physical abuse allegations and terminated following investigation |
| RN #1 | Registered Nurse | Witnessed and reported the abuse incident |
| CNA #2 | Certified Nursing Assistant | Witnessed abuse, intervened to protect resident, and reported the incident |
| CNA #3 | Certified Nursing Assistant | Heard verbal threats during incident |
| DON | Director of Nursing | Confirmed investigation and termination of CNA #1 |
| ED | Executive Director | Confirmed investigation and termination of CNA #1 |
| Divisional Director of Clinical Operations | Confirmed investigation and termination of CNA #1 |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Oct 20, 2022
Visit Reason
The inspection was conducted to investigate complaints related to failure to provide timely transfer notification, inaccurate nurse staffing postings, medication labeling and storage issues, and failure to follow prescribed controlled carbohydrate diets.
Complaint Details
The visit was complaint-related, focusing on issues including failure to provide transfer notification, inaccurate nurse staffing postings, medication labeling and expiration, and diet non-compliance.
Findings
The facility failed to provide a written transfer notice to a resident, did not accurately post daily nurse staffing data, failed to ensure medications were properly labeled and not expired, and did not follow the controlled carbohydrate diet menu for nine residents requiring that diet.
Deficiencies (4)
Failed to provide a written notice of transfer to 1 of 4 sample residents reviewed for a facility-initiated transfer.
Failed to accurately post daily nurse staffing data, missing actual hours worked by resident care staff.
Failed to ensure medications available for use were not expired and properly labeled in 1 of 3 medication storage units.
Failed to follow the controlled carbohydrate (CCHO) diet menu for 9 residents requiring that diet.
Report Facts
Census: 40
Residents affected: 1
Residents affected: 9
Medication storage units reviewed: 3
Medication storage units with deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding transfer notification and medication labeling deficiencies | |
| Administrator | Interviewed regarding nurse staffing posting deficiency | |
| RN #1 | Interviewed regarding medication labeling deficiency | |
| Cook #1 | Interviewed regarding failure to follow diet menu | |
| Certified Dietary Manager (CDM) | Interviewed regarding failure to follow diet menu |
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