Wyoming Healthcare Center

Based on record review and staff interview, the facility failed to investigate allegations of abuse from Resident #213 to other residents in the facility. This was true for 1 out of 1 resident reviewed for allegations of abuse. This has the potential to affect more than a limited number of residents. Resident identifier: 213. Facility census: 55. Findings include: a) Resident #214 Progress Notes At approximately 3:00 PM on 03/25/24, a record review for Resident #213 was conducted as part of the sample selection process. During this process, progress notes were reviewed, which indicated multiple incidents of sexual, physical, and verbal abuse directed at other residents in the facility, by Resident #213. These progress notes were cross referenced with the facility's incident and reportables logs, revealing none of these incidents were investigated or reported. Progress notes of the incidents are as follows: On 02/13/24 at 6:23 PM Resident #213 touched a female resident inappropriately. On 02/19/24 at 11:54 AM, Resident #213 rubbed a female resident's arm and stated, Tell me you love…

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 record review and staff interview, the facility failed to develop and/or implement a care plan for 1:1 visits, a diagnosis for Schizoaffective Disorder, Bed Rails, Wander Guard, Trauma and Dementia diagnosis, Fall Interventions, and Tube Feeding. This was true for eight (8) of 16 sampled residents reviewed during the long term care survey process. Resident identifiers: 36, 33, 7, 25, 48, 20, 213, and 31 Facility census: 55 Findings include: a) Resident #36 On 03/26/24 at 10:15 AM the Activity Director Provided a 1:1 list stating Resident #36 was to have 1:1 visits daily. A record review on 03/26/24 at 11:00 AM of Resident #36's care plan revealed Resident #36 was not care planned to receive daily 1:1 visits. On 03/26/24 at 11:36 AM during a staff interview with the Administrator, it was confirmed the care plan did not include Resident #36's 1:1 visits with activities. b) Resident # 33 On 03/26/24 at 10:15 AM the Activity Director Provided a 1:1 list stating Resident #33 was to have 1:1 visits daily. A record review on 03/26/24 at 11:00 AM of Resident #33's care plan…

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 staff interview, the facility failed to ensure residents were treated in a dignified manner. Resident #162 was administered medication in the dining room on two (2) occasions and Resident #36 was taken to Bingo and the day lounge to watch television in a shirt soiled with tube feeding. These were random opportunities for discovery. Resident identifiers: #36 and #162. Facility Census: 55. Findings included: a) Resident #36 On 03/27/24 during a medication administration observation at approximately 1:30 PM, Resident #36's shirt became soiled with tube feeding when some of the feeding spilt from the syringe used during the feeding. Resident #36's shirt was not changed, and she was taken to the dining room to play Bingo. At 3:05 PM on 03/28/24 Resident #36 was observed sitting in the lounge area with other residents watching a movie. She was still wearing the soiled shirt. Registered Nurse #85 observed the resident with the surveyor at 3:05 PM on 03/27/24 and confirmed her shirt needed to be changed. b) Resident #162 On 03/27/24 at 11:11 am, Resident #162…

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 record review and staff interview the facility failed to identify a diagnosis of schizoaffective disorder on a quarterly Minimum Data Set (MDS). This was a random opportunity for discovery and was true for Resident #20. Resident identifier: #20. Facility census: 55. Findings included: a) Resident #20 On 03/27/24 at 10:03 AM a record review on Resident #20 found the Pharmacy recommendations on 01/05/24. The FNP (Family Nurse Practitioner) had a note stating to add medical diagnosis of schizoaffective disorder and bipolar disorder to the resident's medical record. Further record review on 03/27/24 showed bipolar disorder on Resident #20's medical diagnosis, however, it did not show a medical diagnosis for schizoaffective disorder. A review of the quarterly MDS with an Assessment Reference Date (ARD) of 03/08/24 revealed Resident #20 had a diagnosis of schizoaffective disorder . During an interview on 03/27/24 at 11:00 AM a staff interview with the Corporate Nurse #85, Regional Director #85 and Administrator all confirmed the Diagnosis for Schizoaffective Disorder was not on…

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 record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASRR) for Resident #6, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of 16 residents reviewed during the survey process. Resident identifier: #6. Facility census: 55. Findings included: a) Resident #6 At approximately 2:30 PM on 03/25/24, a record review was conducted for Resident #6. During the Record review, the PASRR for Resident #6 was reviewed. The PASARR, dated 08/19/10, had None marked under the current diagnosis tab of the MI/MR (Mental Illness/Mental Retardation) assessment portion. Upon further review, Resident #6 was diagnosed with major depressive disorder in 2017 and a new PASARR was not completed. At approximately 1:41 PM on 03/27/24, an interview was conducted with the Director of Nursing (DON). During this interview, the DON acknowledged there was no diagnosis on the PASRR for major depressive disorder. The DON also acknowledged Resident #6 had been diagnosed with major…

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 record review and staff interview, the facility failed to add a diagnosis of schizoaffective disorder for one (1) of (16) residents reviewed for the care area of pre-admission screening and resident review (PASARR) this failed practice had the potential to affect a limited number of residents in facility. Resident identifier: #20. Facility census: 55. Findings include: A review of Resident #20's medical record on 03/27/24 found the resident received a diagnosis of Schizoaffective disorder prior to admission. Further Record review of Resident #20's medical record on 03/27/24 of the pre-admission screening and resident review ( PASARR) found the PASARR did not contain a diagnosis of schizoaffective Disorder. An interview on 03/27/24 at 10:10 AM, with Regional Director #86 and Corporate Nurse #85 confirmed the PASARR for Resident #20 did not contain a diagnosis of Schizoaffective Disorder.

Based on record review, observation and staff interview the facility failed to revise Resident #36's care plan when the use of a vest for positioning was discontinued. This was true for one (1) of 16 sampled residents. Resident Identifier: #36. Facility Census: 55. Findings include: a) Resident #36 A record review of Resident #36's care plan on 03/26/24 found the following intervention related to Activities of Daily Living (ADL) performance, Up in high back tilt wheelchair with pommel cushion and vest for positioning. An observation of Resident #36 on 03/25/24 and 03/27/24 found the resident was up in the wheelchair but was not wearing a vest as directed in her care plan. An interview with Nurse Aide #64 at 12:58 PM on 03/27/24 confirmed the resident did not have a vest in place. Nurse Aide #64 stated, She use to have one but we have not used that with her for sometime now. An interview with the Director of Nursing (DON) on 03/27/24 at approximately 2:00 PM found the resident no longer used the vest. She indicated, it had messed up so they switched it to the seat belt. She agreed…

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 record review and staff and resident interview, the facility failed to complete neurological assessments after a fall for Resident #213 and #31, failed to notify the physician of hyperglycemia results for Resident #8, and to administer medication per physician's order for Resident #49. This was true for four (4) out of four (4) residents reviewed for quality of care during the survey process. Resident identifiers: #213, #31, #8, #49. Facility census: 55. Findings included: a) Resident #213 At approximately 10:00 AM on 03/27/24, a record review was conducted for Resident #213 concerning falls at the facility. Upon review, it was determined neurochecks were incomplete for Resident #213 following multiple falls. For a fall at 5:15 PM on 10/20/23, the daily fourth check was not completed. For a fall at 6:35 PM on 12/26/23, the daily second and daily third checks were not completed. The daily fourth check was completed on 03/15/24. For a fall at 7:00 PM on 02/14/24, the fourth one-hour check was documented taking place at 02/14/24 at midnight. The neuro check should have taken…

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, family interview, staff interview and record review the facility failed to provide toenail care to Resident #29. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #29. Facility census: 55. Findings included: a) Resident #29 On 03/25/24 at 12:30 PM Resident #29's husband stated he would like to get her toenails cut. They [facility staff] told him she wasn't eligible, and no one has ever come back to do anything else about it. The resident's toenails on both feet were observed to be thick, yellow in color and curled over top the ends of the toes on both feet. Record review showed no grievance or concerns for toenail care. Resident #29 was admitted to the facility on [DATE]. On 03/26/24 at 2:02 PM electronic health records Licensed Practical Nurse (LPN) #19 stated they have to sign up for [name of contracted services company] then if they are eligible, they can get the services. If they are not…

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 record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #31 did not have his fall interventions in place. The facility to failed to implement fall interventions for Resident #213 regarding his risk for elopement. This was true for two (2) of the 16 sampled residents. Resident identifiers: #31 and #213. Facility Census: 55. Findings Include: a) Resident #31 A review of Resident #31's medical record on 03/26/24 found a fall intervention of bed bolsters to the bed. An observation with the Director of Nursing (DON) and Registered Nurse #85 on 03/26/24 at 10:18 AM confirmed Resident #31's bed bolsters were not in place as directed by his care plan. b) Resident #213 At approximately 3:30 PM on 03/25/24, a review of the care plan for Resident #213 was conducted. During the review, it was noted Resident #213 was care planned to have a wanderguard device on their leg and wheelchair due to wandering behaviors and a history of elopement. At approximately 10:30 AM on…

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, record review and staff interview the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of the enteral feeding tube unless unavoidable. Resident Identifier: Resident #36. Facility Census: 55. Findings Include: a) Resident #36 An observation of medication administration for Resident #36 began on 03/27/24 beginning at 1:10 PM found Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medications. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving the following medication: 1. Isosource 1.5 2. Haldol Tablet five (5) milligrams 3. Midodrine 10 milligrams 4. Norco 5-325 milligrams 5. Baclofen 10 milligrams LPN #35 crushed the Haldol, Midodrine, Norco, and baclofen all together. She stated, I have to crush them because they are administered in her feeding tube. LPN #35 took Resident #36 to…

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 record review and staff interview, the facility failed to properly assess Resident #213 for the use of bed rails. This was true for one (1) of one (1) residents reviewed for bed rails during the long term care survey process. Resident identifier: 213. Facility census: 55. Findings include: A) Resident #213 At approximately 09:30 AM on 03/26/24, an observation of bed rails on Resident #213 ' s bed was made while investigating accident hazards. At approximately 10:00 AM on 03/26/24, a review of the care plan for Resident #213 was conducted. During the review, it was noted that Resident #213 was not care planned to have bed rails on their bed. At approximately 10:15 AM on 03/26/24, a bed evaluation provided by Corporate RN (CRN) #85 stated the resident had interest in bed rails. However, there was no bed rail safety evaluation completed for the resident. CRN #85 confirmed there was no bed rail safety evaluation done on Resident #213. CRN #85 stated There ' s not a bed rail safety evaluation here for that resident. I don ' t even know what a bed rail safety evaluation is.

Based on observation, staff interview and record review the facility failed to ensure Licensed Practical Nurse (LPN) #35 had the appropriate nurse competencies to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of the enteral feeding tube unless unavoidable. LPN #35 did not administer medications and or feedings to Resident #36 via the enteral tube in a correct manner. The facility was unable to show LPN #35's competencies and skills regarding feeding tube care was reviewed upon her hire to the facility in January of 2024. Resident identifier: #36. Facility census: 55. Findings included: a) Resident #36 An observation of medication administration for Resident #36 began on 03/27/24 beginning at 1:10 PM found Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medications. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving…

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 record review and staff interview, the facility failed to notify the physician of a change in baseline behaviors immediately, for a resident with dementia. This was true for one (1) of three (3) residents reviewed for dementia care during the long-term care survey process. Resident identifier: #213. Facility census: 55. Findings include: At approximately 3:30 PM on 03/25/24, a record review was conducted for Resident #213. It was noted Resident #213 had the following diagnosis: Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbances. On 03/22/24, Resident #213 returned from a local behavioral health facility for behaviors. Upon review of behavioral monitoring task sheets, it was determined the resident had worsening behaviors and the physician was not notified until surveyor intervention for an Immediate Jeopardy (IJ) situation, on 03/25/24. The behaviors noted from the task sheets were: 03/23/24 at 11:18 AM-Kicking others, physically aggressive toward others, cursing at others, express frustration/anger at others, screaming…

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, record review and staff interview the facility failed to ensure the facility's medication error rate was five (5) percent or less. The facility's medication error rate was 16.67 percent. Resident identifier: Resident #36. Facility census: 55. Findings include: a) Resident #36 An observation of medication administration for Resident #36 began on 03/27/24 at 1:10 PM. Licensed Practical Nurse (LPN ) #35 was preparing medication for Resident #36. LPN #35 stated, I am giving medication to (Name of Resident #36) this is her noon and 2:00 PM medication. LPN #35 was asked to read each medication as she was pulling them from the medication cart. LPN #35 indicated she was giving the following medication: 1. Isosource 1.5 2. Haldol Tablet five (5) milligrams 3. Midodrine 10 milligrams 4. Norco 5-325 milligrams 5. Baclofen 10 milligrams LPN #35 crushed the Haldol, Midodrine, Norco, and baclofen all together. She stated, I have to crush them because they are administered in her feeding tube. LPN #35 took Resident #36 to her room and began the medication administration 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.

Based on record review and staff interview, the facility failed to maintain an accurate and complete record for two (2) of 16 residents reviewed during the survey process. Residents #19 and #26 did not have an accurate and complete record. Resident #19's record had an incomplete transfer form. Resident #26's record was incomplete in Physician's Scope of Orders for Treatment (POST) form. Resident Identifiers: #19 and #26 . Facility Census: 55. Findings Include: a) Resident #19 On 03/26/24 at 11:00 AM, a record review was completed for Resident #26. The review found the resident was transferred to an acute care facility on 03/15/24. However, the transfer form was reviewed, and the date was listed as 01/28/24. On 03/26/24 at 11:30 AM, the Administrator and the Corporate Registered Nurse (RN) #85 were notified and confirmed the transfer date on the transfer form was incorrect. b) Resident #26 On 03/26/24 at 10:00 AM, a record review was completed for Resident #26. The review found the Physician's Scope of Orders for Treatment (POST) form was not complete. The POST form was signed by…

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 record review and staff interview the facility failed to offer an eligible resident the pneumococcal immunization for one (1) out of five (5) residents reviewed for immunizations. Resident identifier: #39. Facility census 57. Findings included: a) Resident #39 A review of the medical chart found Resident #39 last received a Pneumovax 23 on 06/14/17 which is more than five (5) years and the Resident is eligible for the Prevnar 20. On 09/11/23 at 1:47 PM, the Director of Nursing (DON) stated the facility failed to offer Resident #39 the Prevnar 20 vaccine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure the ombudsman was notified of all residents' transfers to the hospital. This was true for one (1) of four (4) residents reviewed for the care area of hospitlizations. Resident indentifier: #35. Facility census: 53. Findings included: a) Resident #35 Review of Resident #35's medical records showed the resident was transferred to the hospital on [DATE] due to decreased level of consciousness. During an interview on 09/27/22 at 2:02 PM, the Administrator stated a list of the facility's discharges for August 2022 had been sent to the ombudsman on 08/30/22 but Resident #35 was not on this list. The Administrator stated she corrected this today. .

Based on observation, record review and staff interview, the facility failed to accurately revise the comprehensive care plan for one (1) of two (2) residents reviewed for the care area of pressure ulcers. Resident identifier: #44. Facility census: 53. Findings included: a) Resident #44 Review of Resident #44's physician's orders showed an order written on 09/21/22 to cleanse the pressure ulcer to left outer ankle with wound cleanser, pat dry, and apply sure prep. On 09/27/22 at 10:34 AM, Registered Nurse #38 was observed performing the treatment to Resident #44's left outer ankle pressure ulcer. RN #38 stated Resident #44 had other pressure ulcers that healed. Review of Resident #44's comprehensive care plan showed the following focus, [Resident's name has pressure area to right outer ankle. Pressure area to left ankle has resolved. This focus was updated on 09/21/22. During an interview on 09/28/22 at 8:55 AM, the Director of Nursing confirmed Resident #44's care plan was incorrect, and the resident had a current left ankle pressure ulcer and resolved right ankle pressure ulcer. .

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders for medication parameters and failed to perform neurological assessments according to professional standards of practice. This had the potential to affect one (1) of 15 residents reviewed during the long-term care survey process. Resident identifier: #35. Facility census: 53. Findings included: a) Resident #35 1) Medication parameters Review of Resident #35's physician's orders showed an order written on 02/21/22 for the medication atenolol, 25 mg, to be given twice a day for hypertension. The physician's order stated to hold the medication for a pulse rate less than 60. Review of Resident #35's Medication Administration Record (MAR) showed Atenolol had been administered on 09/10/22 at 9:00 AM when the resident's pulse was documented as 56. During an interview on 09/27/22 at 11:19 AM, the Administrator confirmed Resident #35 had been administered Atenolol on 09/10/22…

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 record review and staff interview the facility failed to maintain accurate documentation for administration and dispensing of pain medication for Resident #46 and #55. This failed practice was a random opportunity for discovery. Resident identifiers: #46, and #55. Facility census: 53. Findings included: a) Resident #46 Review of Resident #46's orders indicated an order for pain medication, Percocet Tablet 5-325 mg give one tablet by mouth every 6 hours as needed for pain. Start date of 05/02/22. Record review of the residents Medication Administration Record (MAR) compared to the individual resident's-controlled substance record (used to sign controlled substances out of medication cart) indicated the following discrepancies in documentation for Percocet Tablet 5-325 mg administered by Licensed Practical Nurse (LPN) #64 in September 2022: 09/21/22 - no tablets were signed out of inventory. One (1) tablet was documented as administered at on the MAR at 9:53 PM. 09/22/22 - One (1) tablet was signed out of inventory at 9:53 PM and one (1) tablet signed out at 6:00 AM, and one…

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.