Inspection Reports for The Cortland Wyoming

The investigation was initiated due to a complaint alleging that Resident A's fingernails had not been cut and that Resident A refused medications and was combative.

The investigation found that the allegation regarding Resident A's uncut fingernails was not substantiated due to Resident A's resistance to care. However, violations were established related to medication administration, including failure to notify the physician when medications were refused and incomplete medication logs.

The complaint alleged Resident A’s fingernails had not been cut and that Resident A refused medications and was combative. The fingernail allegation was not substantiated, but the medication refusal and related issues were substantiated.

The inspection was conducted following a complaint received from Adult Protective Services alleging that Resident B was found in a urine-soaked bed without clothes or bedding.

The investigation confirmed that Resident B was found lying in bed without clean linens, only a blanket, and was incontinent. Staff were unaware of the missing bedding, and Resident B's service plan lacked specific details regarding care needs and frequency of checks. Violations were established related to bedding and resident care.

Complaint was received from Adult Protective Services on 03/19/2025 regarding Resident B being found in urine-soaked bed without clothes or bedding. The complaint was substantiated with violations established.

The investigation was initiated due to a complaint alleging that Resident A was left unattended outside on 10/7/24 and fell headfirst over the curb, resulting in injury and death. There was also an allegation that staff at the facility were not trained.

The investigation established that Resident A fell out of his wheelchair while unattended outside, which was inconsistent with his service plan that required supervision and assistance. The facility was found not in compliance with the rule regarding resident safety and supervision. The allegation that staff were not trained was not substantiated, as staff training records and interviews confirmed adequate training.

The complaint alleged Resident A was unattended outside on 10/7/24 and fell headfirst over the curb, resulting in injuries and death. The complaint also alleged staff were not trained. The violation regarding Resident A's unattended fall was established, while the allegation regarding staff training was not established.

The inspection was conducted as a renewal licensing study for The Cortland Wyoming facility to assess compliance with applicable rules and regulations.

The facility was found to be in non-compliance with multiple rules related to laundry and linen storage, kitchen and dietary sanitation, food labeling, and hazardous materials storage. Violations included improper storage of clean linens, unclean food service surfaces, incomplete dishwasher sanitization records, unlabeled food items, and unsecured hazardous materials accessible to residents.

The investigation was initiated due to a complaint alleging that facility staff did not provide appropriate care for Resident A in a timely manner and that Resident A incurred a fall resulting in injury due to unsafe transfer technique by care staff.

The investigation established violations including failure to provide appropriate supervision and assistance to Resident A upon hospital returns, resulting in Resident A's decline and death; unsafe transfer technique by staff causing Resident A's fall and injury; lack of a current appointed administrator; failure to notify the department of administrator vacancy within required timeframe; and incomplete and unsigned resident records.

Complaint received on 2023-10-24 alleging failure to provide timely appropriate care to Resident A and unsafe transfer technique causing injury. Violations were substantiated.

The investigation was initiated due to complaints alleging the facility did not provide Resident A showers in a timely manner or according to the service plan, and did not provide medication administration in accordance with physician orders and service plans to Resident A and Resident B.

The investigation found multiple violations including failure to provide showers to Resident A consistent with the service plan, failure to administer medications according to physician orders and service plans for Residents A and B, lack of current service plans, incorrect medication documentation, lack of evidence of staff re-education, and unsecured medication found accessible on the medication cart.

The complaint was received on 2023-10-24 and the investigation was initiated on 2023-10-26. The allegations included failure to provide showers to Resident A as per service plan and failure to administer medications properly to Residents A and B. Violations were established for all allegations.

The inspection was conducted in response to a complaint alleging that the facility did not provide Resident A appropriate care or supervision in accordance with the service plan.

The investigation established violations related to failure to provide appropriate care and supervision to Resident A, including incidents in March and April 2023 where Resident A ate dry hot chocolate mix causing coughing and heels were not properly floated. Additionally, the facility failed to provide an updated service plan for Resident A.

The complaint alleged that Resident A was not provided appropriate care or supervision for 48 hours during the 2022 New Year holiday weekend and was left in urine and feces for 12 hours. The investigation found no evidence supporting these specific allegations but did find other violations related to care and service plan documentation.

The inspection was conducted in response to a complaint alleging that Resident A had blood drawn by an outside agency without a physician's order.

The investigation confirmed that Resident A had an unauthorized blood draw on 5/15/23 without a physician's order. The blood draw occurred in the dining room of the secured memory care unit where others could observe, which is inconsistent with an organized program of protection.

The complaint alleged that Resident A's blood was drawn by an outside agency without an order, specifically noting the blood draw took place in the dining room between 12:30 and 1:30 PM by a person not wearing scrubs but a name tag. The violation was established based on interviews and review of documentation.

The inspection was conducted as a renewal licensing study to evaluate compliance with licensing rules and regulations for Vista Springs Wyoming.

The facility was found to be in non-compliance with multiple rules including medication management, meal and food records, waste management, laundry and linen storage, kitchen sanitation, dishwasher sanitization records, ice scoop storage, food safety, and hazardous materials storage. Violations were established for each cited rule.

The inspection was conducted in response to a complaint alleging staff members bring children to work and that residents are treated disrespectfully, including concerns about bruises, bedsores, and staff behavior.

The investigation found that the allegation of staff bringing children to work was an isolated incident and not systemic. Allegations of residents being treated disrespectfully were not substantiated. However, a violation was established due to lack of detail and instructions in a resident's service plan regarding combative behavior.

Complaint alleged staff bring children to work and residents are treated disrespectfully with bruises and bedsores. The allegation of staff bringing children to work was not established as a violation. The allegation of disrespectful treatment was not substantiated. Additional finding of violation was established related to Resident C's service plan lacking necessary detail.

The inspection was conducted in response to an anonymous complaint alleging the facility was not following Covid-19 protocols, including employees working while Covid-19 positive and spreading the virus to residents.

The investigation found that the facility had a recent Covid-19 outbreak with 10 residents and 10 employees testing positive. The facility generally followed Covid-19 protocols including removing Covid-positive employees from the schedule for five days and providing PPE. However, the facility failed to enforce mask-wearing for visitors, which was a violation of their internal policy and posed a risk to resident protection.

Complaint was anonymous alleging the facility was not following Covid-19 protocols, including employees working while Covid-19 positive and spreading the virus to residents. The complaint was substantiated with violation established.

The investigation was initiated due to a complaint alleging that Resident A eloped from the facility on 11/11/2022.

The investigation found that Resident A eloped through a side door without alerting staff or signing out and was found in a neighbor's backyard. Staff did not document required frequent rounding checks prior to the elopement, and no staff was present at the front desk during the inspection. A violation was established due to failure to maintain proper supervision and documentation.

Resident A eloped from the facility on 11/11/2022. The violation was established based on interviews, documentation review, and inspection findings.