Medilodge of Wyoming

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent and offer information about formulating an Advanced Directive for 1 resident (R82) out of 5 residents reviewed for Advanced Directives. Findings include: Review of an admission Record reflected R82 admitted to the facility on [DATE] with diagnoses that included encephalopathy (a brain disease that can appear as confusion, memory loss, personality changes and/or coma), cognitive communication deficit, mild cognitive impairment, major depression, and generalized anxiety disorder. Review of a form Advanced Directives Acknowledgements/CPR (Cardiopulmonary Resuscitation) Consent reflected what CPR is; Acknowledgments, including spaces after each statement for initials to indicate understanding,I have been informed of my rights and all rules and regulations regarding decisions regarding medical care; I have been fully informed of my options when choosing CPR or Do Not Resuscitate (DNR) services; I understand I have the right to alter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician reviewed monthly drug regimen review recommendations for 1 resident (R70) of 5 residents reviewed for unnecessary medication. Findings include:Review of an admission Record revealed R70 admitted to the facility on [DATE] with pertinent diagnoses which included hypertension and gastro-esophageal reflux disease (GERD).Review of R70's drug regimen review Physician Recommendations dated 6/14/2025 revealed .This resident is receiving famotidine 20mg BID (twice daily) for GERD since 03/2023. Please evaluate for continued need/reduction. There was no indication that the physician had reviewed this recommendation.Review of R70's Physician's Orders on 7/14/2025 at 11:14 AM revealed an active order for famotidine 20mg to be taken by mouth twice a day. Further review of the electronic medical record revealed no documentation that the physician had reviewed the drug regimen review Physician Recommendations dated 6/14/2025.In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain proper infection control practices for one of two Residents (R69) observed during clinical care activities. Findings include:Resident #69 (R69)On 7/23/25 at approximately 9:41 AM, RN C administered a prescribed nasal spray to R69. RN C prepared to give R69 their insulin injection via pen in the abdomen by cleansing the area with alcohol swab. RN C then waved her hand back and forth over the area swabbed by alcohol to get it dried prior to administering the insulin injection. According to the World Health Organization (WHO) 2020, injections are unsafe when administered with unsterile or improper techniques. The WHO recommends swabbing the injection site for 30 seconds and allowing the area to dry for 30 seconds. RN C waving their hand over the alcohol causes it to evaporate too quickly, disrupting the alcohol's action, while potentially introducing new microorganisms. RN C's actions can increase the risk for infection at the injection site. Upon return to the medication cart, RN C did not cleanse the nasal applicator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor resident choices and preferences based on the individualized plan of care for 1 resident (Resident #40) out of 16 residents reviewed for self-determination. Findings: Resident #40 (R40) Review of an admission Record reflected R40 admitted to the facility with diagnoses that included muscle weakness, need for assistance with personal care, repeated falls, chronic post-traumatic stress disorder PTSD), dependence on enabling machines and devices and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflects R40 is cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15. Review of a Care Plan initiated on 7/20/2023 reflected R40 required assistance with Activities of Daily Living (ADL) related to his diagnoses. Interventions included: Transfers: 2 person assist with Hoyer (mechanical) lift (added to the care plan on 6/14/2024); I like to sit up in my recliner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards regarding medication administration for 1 of 6 residents (Resident #57), reviewed for professional standards. Findings: Resident #57 (R57) Review of an admission Record revealed R57 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of stroke, legal blindness, repeated falls, and anxiety disorder. During an observation on 08/21/24 at 10:15 AM, R57 laid in bed resting with his eyes open and a small plastic cup containing multiple pills sat on the overbed table. R57 stated that sometimes the nurse would leave his morning medications for him to take when he wakes up. R57 also reported that he does not take his medications independently, nor store any of his medications in his room. Review of the Electronic Health Record (EHR) for R57 revealed there was not an assessment nor a physician order for R57 to self-administer medications. During an interview on 08/23/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure accurate skin assessments and timely responses to skin changes for 2 of 16 residents, (Resident #22 and Resident #54) reviewed for impaired skin. The deficient practice resulted in no follow-up assessments and treatment orders for identified skin conditions. Findings include: Resident #54 (R54) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R54 admitted to the facility on [DATE] with diagnosis of (but not limited to) stoke, chronic pain syndrome, and heart failure. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which represented R54 was cognitively intact. During an interview and observation on 8/20/24 at approximately 3:53 PM, R54 was asked if she had any wounds the staff was monitoring and R54 stated she had no wound dressings. R54 stated that she was told she needed surgery for a skin issue on her right breast. R54 pulled her shirt up and showed this Surveyor a darked,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 1 resident (Resident #3) and residents attending monthly group meetings, reviewed for dignity, resulting in the potential for feelings of frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being. Findings: Resident #3 (R3) Review of an admission Record revealed R was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis. Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 5/8/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R3 was cognitively intact. During an interview on 07/25/23 at 12:15 PM, R3 reported that she felt it was disrespectful when the facility nursing staff wore earbuds while they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to failed to ensure call lights were in reach and answered promptly for 3 residents (Resident #224, #8, and #63), reviewed for accommodation of needs, resulting in the potential for residents to not meet their highest practicable level of well-being. Findings include: Resident #224 (R224) Review of an admission Record revealed R224 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke and aphasia (difficulty speaking). R224 was able to make needs known but had difficulty speaking. During an observation and interview on 07/25/23 at 09:40 AM, R224's call light was on and he reported he had been waiting for assistance for over an hour. R224 pointed to his wheelchair and indicated he was waiting to be assisted out of bed. Review of the call light system located at the nurses station revealed R224's call light had been activated at 9:32 AM. At 9:48 AM, Certified Nursing Assistant (CNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were kept safe from accidents and hazards for 1 residents (Resident #8) when staff failed to maintain NPO (nothing by mouth) status, resulting in the potential for harm from complications related to the resident's inability to swallow safely. Findings: Resident #8 (R8) Review of an admission Record reflected R8 admitted to the facility on [DATE] with pertinent diagnoses of blindness of one eye, osteoarthritis, muscle weakness, need for assistance with personal care, gastrostomy status (feeding tube), low back pain and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] reflected R8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15 and needed extensive assistance from one person for dressing, toileting and bathing. Review of a Speech Therapy SLP Evaluation and Plan of Treatment for certification period 6/30/2023 - 7/29/2023 reflected R8's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure systems were implemented to accurately account for controlled substances when licensed nurses were not conducting/signing off on shift to shift narcotic reconciliation and licensed nurses were not signing out controlled substances from narcotic sheets prior to administration of the controlled substances, resulting in the potential for the inability to reconcile narcotics and diversion. Findings: Review of a facility policy Controlled Substance Administration & Accountability reviewed/revised on 1/1/2022 reflected It is the policy of this facility to promote safe, high quality patient, care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. The policy specified 8. The Charge Nurse on duty will maintain the keys to the controlled substance containers. The keys to this container should not be shared with other staff, including licensed staff without first…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.