Wyoming Retirement Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on incident and grievance review, resident and staff interview, state survey agency incident database review, and policy and procedure review, the facility failed to ensure allegations of abuse were reported timely for 3 of 12 sample residents (#24, #29, #33) reviewed for abuse allegations. The findings were: 1. Review of an incident report dated 11/3/24 showed resident #72 was upset because his/her meal was not to his/her liking. The resident became verbally aggressive towards staff then walked away. At that time, resident #29 was moving up the hallway in his/her power wheelchair and both residents declined to step around or give room for the other to get by. Resident #72 stepped in front of resident #29 then accused resident #29 of running into him/her. Resident #72 then struck resident #29 with an open hand on the right side of his/her face. Further review showed the allegation was not reported until 11/12/24, 9 days after the incident. 2. Review of a Resident Grievance Record dated 11/5/24 showed…

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 medical record review, resident and staff interview, facility incident and grievance review, and policy and procedure review, the facility failed to ensure allegations of abuse were thoroughly investigated for 2 of 12 sample residents (#24, #33) with reviewed for abuse. The findings were: 1. Review of a Resident Grievance Record dated 11/5/24 showed resident #33 made statements of I want my table back, Table mate is being mean to me, and I don't want to eat because of [him/her]. Further review showed the resident was eating in his/her room as a result. The following concerns were identified: a. Interview with resident #33 on 12/12/24 at 8:58 AM revealed his/her previous tablemate said mean things to him/her and wanted to fight him/her. The statements upset the resident and s/he decided to eat in the unit instead of the main dining room. The resident revealed s/he did not want to return to the main dining room because of what was said to him/her. b. Review of a progress note for resident #33 dated…

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 medical record review, staff interview, facility investigation review, and policy review, the facility failed to implement treatment in accordance with the care plan for 1 of 9 sample residents (#48) reviewed for accident hazards. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #48 had short-term and long-term memory problems and diagnoses which included fracture of the right femur, atrial fibrillation, and dementia. The resident had a BIMS score of 3 out 15, which indicated severe cognitive impairment. Review of the care plan last revised on 9/12/24 showed resident #48 was dependent on staff for all transfers, using a gait belt. The following concerns were identified: a. Review of a progress note dated 10/20/24 and timed 5:30 AM showed CNA states that resident was being transferred X [times] 1 assist from wheelchair to bed. At this time staff member states that resident was trying to pull [his/her] brief down, and CNA attempted to help resident pull it…

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 medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitored for 1 of 5 sample residents (#36) and failed to ensure PRN orders for psychotropic medications were limited to 14 days for 1 of 5 sample residents (#67) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had a BIMS score of 9 out 15, which indicated moderate cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, depression, and schizophrenia. The MDS showed the resident had a mood score of 0, which indicated no signs or symptoms of depression, and there were no behaviors exhibited. Further review showed the resident received antipsychotic medication and antidepressant medication during the look-back period. Review of the physician orders showed the resident received risperidone (antipsychotic) 0.5 mg by mouth daily at bedtime for mood…

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 medical record review, staff interview, MDS 3.0 RAI manual review, and policy and procedure review, the facility failed to ensure MDS assessment information was an accurate reflection of resident status for 2 of 18 sample residents (#19, #25). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #25 was coded as having a stage 3 pressure ulcer. Review of the comprehensive MDS assessment dated [DATE] showed the resident was coded as having a stage 3 pressure ulcer. The following concerns were identified: a. Review of the medical record showed no evidence the resident had a pressure ulcer since 2021. b. Interview with DON on 9/27/23 at 9:54 AM confirmed the resident did not have an actual wound since 2021 and the MDS assessments were not accurate. c. According to the MDS RAI Manual version 1.71.1 page 440 showed .Coding Instructions for M0300C M0300C1 Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 3. Enter 0…

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 medical record review, staff interview, and policy and procedure review, the facility failed to ensure an adequate assessment was performed and appropriate interventions were implemented for 1 of 4 sample residents (#25) reviewed for nutrition. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #25 had diagnoses which included renal insufficiency, renal failure, or end-stage renal disease, Parkinson's disease, other specified nutrition deficiencies, and gastro-esophageal reflux disease. Further review showed the resident required extensive physical assistance of 1 person for eating and no weight loss was indicated. The following concerns were identified: a. Review of the resident's weight history showed the resident weighed 167.3 pounds on 7/30/23 and 151 pounds on 8/7/23 which was a 16.3 pound or 9.74% loss, in 8 days. The resident weighed 129.8 pounds on 8/30/23 which was a 37.5 pound or 22.41% loss, in 31 days. The resident's weight continued to decrease 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy review, the facility failed to ensure a gradual dose reduction or risk versus benefit was performed for 1 of 5 sample residents (#39) reviewed for unnecessary medications. In addition, the facility failed to ensure as needed psychotropic medications were not ordered for greater than 14 days without physician rationale for 1 of 5 sample residents (#4) unnecessary medications. The findings were: 1. Review of the 9/16/23 quarterly MDS assessment for resident #4 showed the resident had a brief interview for mental status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment, and diagnoses which included anxiety and depression. Review of the physician's orders for September 2023 showed the resident received lorazepam 0.5 mg1 tablet by mouth every 12 hours as needed (PRN) for lifetime of patient, related to anxiety disorder ordered on 2/23/22. Review of the resident's care plan last revised on 6/27/23 showed to consult with the…

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, medical record review, review of the facility infection control line listing, and staff interview, the facility failed to develop and/or implement the care plan for 3 of 22 sample residents (#29, #32, #68). The findings were: 1. Review of progress notes showed on 5/6/22 at 3:15 AM resident #68 was not in his/her room. Facility staff searched for the resident and found the resident outside of the south courtyard laying on the ground (in the grassy area). The resident stated I was trying to get back in. Review of the care plan provided by the DON on 7/13/22 at 12:32 PM showed the resident had exited the building and was found outside by staff. Interventions included Verify wanderguard placement daily and monitor battery function weekly. The following concerns were identified: a. Review of the medical record, including the medication administration record (MAR) and treatment administration record (TAR), showed no documentation staff were verifying wanderguard placement daily or checking the battery function weekly. b. On 7/13/22 at 5:05 PM the DON reviewed the…

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 medical record review and staff interview, the facility failed to ensure all components of the discharge summary were incorporated and documented for 1 of 1 sample residents (#73) reviewed for discharge. The findings were: Review of the 6/22/22 discharge MDS assessment showed resident #73 was discharged on 6/22/22. Review of a 6/22/22 discharge summary progress note timed 1:15 PM showed .Resident left with staff member to be taken to [an assisted living facility]. Resident left with all personal belongings, all medications (copies of bubble packs made), any money [s/he] had locked in office safe . The following concerns were identified: a. Review of the medical record and discharge documentation showed a post-discharge plan of care, and a reconciliation of the resident's medications. However, there was no documentation of a recapitulation of the resident's stay, or a final summary of the resident's status at the time of discharge. b. Interview on 7/14/22 at 11:29 AM with the administrator and medical records director confirmed the two components were missing. They revealed…

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 medical record review, staff interview, review of facility incident reports, and policy and procedure review, the facility failed to provide appropriate assessments and monitoring for 1 of 2 sample residents (#21) reviewed for falls. The findings were: Review of the 5/7/22 quarterly MDS assessment showed resident #21 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, pain, fall from non-moving wheelchair, and chronic fatigue. Review of the current care plan, last revised 5/18/22, showed The resident has had an actual fall with no injury related to poor balance 1/24/20, 3/1/20, 4/28/22 with interventions that included Check range of motion at time of fall, Monitor/document/report [as needed] x 72h to MD for [signs and symptoms]: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Neuro-checks per facility policy, and Vital signs [once per shift]. Take [blood pressure] lying/sitting/standing x1 in 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.

Based on observation, medical record review, and staff interview, the facility failed to implement interventions to prevent re-occurrence for 1 of 3 sample residents (#68) who eloped from the facility. The findings were: Review of the 4/9/22 quarterly MDS assessment revealed resident #68 had a BIMS score of 0 (severe cognitive impairment), required limited assistance with ambulation, and wandered 1-3 days. Observation on 07/12/22 at 11:48 AM showed the resident ambulated to the dining room by him/herself using a walker. Review of progress notes showed on 5/6/22 at 3:15 AM the resident was not in his/her room. Facility staff searched for the resident and found the resident outside of the south courtyard laying on the ground (in the grassy area). The resident stated I was trying to get back in. During an interview on 7/12/22 at 4:37 PM the DON stated the resident eloped out of the front doors and did not have a wanderguard (bracelet worn by resident which triggers door alarm) at the time of the incident because s/he had never tried to exit the facility. Review of a 5/6/22 elopement…

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, medical record review, review of the facility infection control line listing, staff interview, and review of policy and procedure, the facility failed to ensure infection control practices were enforced for 1 of 6 residents (#32) reviewed who had tested positive for COVID-19. At the time of the survey, the facility had 19 residents who had tested positive for COVID-19. The findings were: Review of the 5/21/22 quarterly MDS assessment showed resident #32 was admitted to the facility on [DATE], with diagnoses that included hypertension, nasal congestion, wheezing, unspecified dementia without behavioral disturbance, allergic rhinitis, and shortness of breath. Review of current physician orders showed a 7/8/22 order for In room isolation with droplet precautions every shift related to Covid-19 until 7/16/22. Review of the current care plan, last revised 7/13/22, showed a problem area as At risk for Covid-19 infection [related to] global pandemic. Tested positive for Covid on 7/7/22 with…

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.