Casper Mountain Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of policy and procedures, the facility failed to have a system in place to maintain documentation residents were provided education regarding the benefits and potential side effects of the COVID-19 vaccination and documentation of the consent or refusal of the immunization for 4 of 4 sample residents (#9, #10, #59, #84) reviewed for immunizations. The findings were: 1. Review of the 7/28/25 quarterly MDS assessment for resident #9 showed s/he was admitted to the facility on [DATE] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 2. Review of the 8/8/25 quarterly MDS assessment for resident #10 showed s/he was admitted to the facility on [DATE] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record…

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 the advanced directive was formulated and accurate for 2 of 28 sample residents (#84, #93) reviewed. The findings were: 1. Review of the electronic medical record (EMR) showed resident #84 was listed as do not resuscitate (DNR). Further review of the medical record showed no evidence the resident had signed and dated an advance directive. Interview with the interim DON and MDS coordinator on [DATE] at 5:37 PM confirmed there was no evidence the resident had elected a DNR status. 2. Review of the EMR showed resident #93 was listed as a full code status. Review of a cardiopulmonary resuscitation (CPR) designation form provided by the interim DON on [DATE] at 4:48 PM was initialed No, do not administer CPR and signed and dated by the resident on [DATE]. Interview with the interim DON on [DATE] at 4:48 PM confirmed the EHR did not match the most recent election of no CPR. 3. Review of the Advance Directive…

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 and staff interview, the facility failed to ensure residents were free from unnecessary medications for 2 of 5 residents (#9, #20) reviewed for unnecessary medications. The findings were: 1. Review of the 3/10/25 quarterly MDS assessment showed resident #9 was admitted to the facility on [DATE] and had a diagnosis of schizophrenia. The resident was coded as receiving antipsychotic, antianxiety, and antidepressant medications during the 7-day look-back period. The last attempted gradual dose reduction (GDR) was documented as occurring on 12/31/24. The following concerns were identified: a. Review of the 8/24/25 Psychotropic Medication Utilization Report showed the resident was prescribed quetiapine fumarate (antipsychotic) and buspirone hydrochloride (an antianxiety medication), for paranoid schizophrenia with the last risk-benefit statement completed on 9/17/24; however, the facility was unable to locate the risk-benefit statement signed by the resident's physician or documentation…

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 review of the MDS RAI manual, the facility failed to ensure a significant change MDS assessment was completed for 1 of 28 sample residents (#10). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 0 out of 15 which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain injury, alcoholic cirrhosis of the liver, non-Alzheimer's dementia, and depression. Further review showed the resident was coded as being on hospice care. The following concerns were identified: a. Review of the resident's medical record showed a Discharge Summary from hospice with a discharge effective date of 5/9/25 due to lack of decline. b. Interview with the interim DON on 8/26/25 at 5:53 PM confirmed the resident was discharged from hospice on 5/2/25 and revealed the facility was not notified of the discharge by hospice until 7/7/25. c. Review of the Long-Term Care Facility Resident Assessment…

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, staff interview, and review of the MDS RAI manual, the facility failed to ensure MDS assessments were accurate for 3 of 28 sample residents (#10, #12, #55). The findings were: 1. Review of the 2/9/22 Wyoming PASRR (pre-admission screening and resident review) Level II Determination Summary Report showed resident #12 had psychiatric diagnoses which included bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and sleep terror. Further review showed the resident met the state definition of mental illness. The following concerns were identified: a. Review of the 7/1/25 annual MDS assessment showed section A1500 was marked no to the question if the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability. b. Interview on 8/26/25 at 2:38 PM with the MDS coordinator confirmed section A1500 was marked inaccurately. 2. Review of the 4/18/25 annual MDS assessment for resident #55 showed section GG (used to assess functional abilities and goals) was marked as…

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 and staff interview, the facility failed to ensure an environment was free from accident hazards for 2 of 3 residents (#7, #9) reviewed for smoking. The findings were:1. Review of the quarterly MDS assessment, dated 7/29/25, showed resident #7 had a BIMS score of 14 out of 15 (cognitively intact). The following concerns were identified:a. Observation on 8/25/25 at 3:59 PM showed the resident smoked in the courtyard during the scheduled smoking time.b. Review of the resident's medical record showed the last safe smoking evaluation was dated 3/10/25. Review of the resident's care plan, last updated 6/12/25, did not address smoking.2. Review of the 12/8/24 annual MDS assessment for resident #9 showed s/he was admitted to the facility on [DATE], had a BIMS score of 13 out of 15 (cognitively intact), and had diagnoses which included schizophrenia, respiratory failure, and COPD (chronic obstructive pulmonary disease). Review of the resident's care plan, dated 3/31/23, showed the resident…

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 record review, staff interview, and policy and procedure review, the facility failed to ensure residents with mental disorders received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 sample residents (#30) reviewed for behavioral and emotional needs. The findings were: 1. Review of the comprehensive MDS assessment dated [DATE] showed resident #30 had a BIMS score of 15 out of 15 which indicated intact cognition, and diagnoses which included bipolar disorder, other specified depressive episodes, other mixed anxiety disorders, cognitive communication deficit, and drug induced subacute dyskinesia. Review of the 5/18/25 quarterly MDS assessment showed the resident exhibited physical behavioral symptoms directed toward others 1 to 3 days of the 7-day look-back period, verbal behavioral symptoms directed at others 1 to 3 days of the 7-day look-back period, and rejection of evaluation or care 1 to 3 days…

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 review of the interim DON's pharmacist monthly medication review binder, the facility failed to have a system in place to ensure the pharmacist's monthly medication reviews and recommendations were acted upon and documented in the resident's record for 1 of 5 sample residents (#9) reviewed for unnecessary medications. The findings were: Review of the 3/10/25 quarterly MDS assessment showed resident #9 was admitted to the facility on [DATE] and had a diagnosis of schizophrenia. The resident was coded as receiving antipsychotic, antianxiety, and antidepressant medications during the 7-day look-back period. Review of the resident's medical record and the interim DON's pharmacist monthly medication review binder showed no evidence the pharmacist had performed a monthly medication review which included any irregularities or recommendations for March, April, May, or June of 2025. Interview with the interim DON on 8/27/25 at 12:56 PM revealed she was in the process…

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, staff interview, and manufacture instructions, the facility failed to label medications with the date opened in 1 of 4 medication storage areas (400 hall medication cart). The findings were: 1. Observation of the 400 hall medication cart on 8/26/25 at 12:07 PM showed a Lantus vial which was opened and undated. Review of the manufacturer's instructions titled Patient Medication Information - Lantus Vial last revised 12/1/21 showed opened insulin vials must be discarded after 28 days of opening. 2. Interview with RMA #1 on 8/26/25 at 12:07 PM revealed staff were responsible for labeling multidose vials of medications to indicate the date the medication was opened.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policies, the facility failed to have a system in place to maintain documentation residents were provided education regarding the benefits and potential side effects of the pneumococcal and influenza vaccines and documentation of the consent or refusal of the immunization for 1 of 4 sample residents (#59) reviewed for immunizations. The findings were: 1. Review of the 8/8/25 annual MDS assessment showed resident #59 was admitted to the facility on [DATE]. Further review of the MDS assessment showed the resident was offered and had declined the influenza and pneumococcal vaccines. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 2. Interview with the interim DON and ADON on 8/26/25 at 3:14 PM confirmed no further documentation was available. 3. Review of the Influenza Vaccine policy showed 1. Between…

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, staff interview, and scope of practice review, the facility failed to ensure staff provided care appropriate for their scope of practice for 2 of 6 sample residents (#1, #14) reviewed for wound care. The findings were: 1. Observation on 5/16/25 at 10:38 AM showed MA-C #1 entered the room of resident #14. The MA-C performed hand hygiene, donned gloves, and placed a barrier under the resident's legs. She removed a dressing on the resident's left shin which exposed an open wound with visible discoloration and a pudding thick discharge which was yellow in color. The MA-C applied Vashe solution (hypochlorous acid) on a gauze pad and placed the gauze on the wound which she told the resident had to sit for 10 minutes. The MA-C doffed her gloves and washed her hands, donned clean gloves, and applied lotion to right leg. The MA-C removed her gloves and washed her hands, donned clean gloves, and removed the gauze from the resident's left shin wound. At that time, the yellow…

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, staff interview, and policy and procedure review, the facility failed to ensure enhanced barrier precautions were implemented for 1 of 2 sample residents (#14) during wound care. The findings were: 1. Observation on 5/16/25 at 10:38 AM showed MA-C #1 entered the room of resident #14. The MA-C performed hand hygiene and donned gloves and performed wound care for the resident. Observation showed the resident had wound care performed to an open wound on his/her left shin and an open area to one of his/her left toes. Observation showed a plastic container which contained personal protective equipment, including gowns, was located near the resident's bed. Further observation showed the MA-C did not wear a gown during the wound care. 2. Interview with the infection preventionist/staff development coordinator on 5/16/25 at 1:22 PM revealed enhanced barrier precautions should be used for all residents with wounds, catheters, and dialysis or other types of ports. Further interview revealed gloves and gowns should be worn for enhanced barrier precautions during wound…

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, family, resident, physician and staff interview, and policy and procedure review, the facility failed to give medications according to physician instruction for 1 of 3 sample residents (#1) reviewed. The findings were: 1. Review of the 3/26/25 admission MDS assessment showed resident #1 had diagnoses that included infrarenal abdominal aortic aneurysm, acute kidney failure, atherosclerosis of renal artery, anxiety disorder, congenital renal artery stenosis and cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery. Review of the medical record showed the resident re-admitted to the facility from the hospital on 3/26/25 at 4:55 PM. The following concerns were identified: a. Review of the March 2025 MAR showed an order for Nifedipine ER Oral Tablet extended release 24 Hour, give 30 milligrams by mouth at bedtime. Further review showed the box that indicated who provided the medication was marked with an x. b. Review of a physician note dated 3/27/25 and timed at 9:59 AM showed CMR was unable to get [his/her]…

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 resident, friend and staff interviews, and review of policies and procedures and incident reports, the facility failed to ensure the resident had the right to receive visitors of his/her choosing for 1 of 5 sample residents (#7) reviewed for residents rights/visitation. The findings were: 1. During an interview on 3/5/25 at 3:20 PM resident #7 stated that his/her friend was no longer able to visit because the facility issued a no trespass order with the police. The resident stated in February his/her friend visited in the facility. When the friend was headed to the front door to leave, another resident accused resident #7 of hitting him/her when resident #7 wheeled by in the w/c. The resident stated s/he didn't hit the other resident. The resident stated his/her friend saw the whole thing and was yelling at that other resident [s/he] didn't hit you. Later, the police called the resident's friend and stated s/he was no longer allowed to visit because a no trespass order was issued by the facility. The resident was upset his/her friend was no longer able to visit. 2. 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 medical record review, and staff and family interview, the facility failed to ensure the resident's physician was notified of a significant change in condition for 1 of 3 sample residents (#4) reviewed for changes in condition. The findings were: 1. Review of the 1/16/25 admission MDS assessment showed resident #4 had diagnoses including heart failure and diabetes mellitus and did not have any wounds. Review of progress notes dated 1/17/25 showed the resident did not have any edema and had no documented skin concerns. The following concerns were identified: a. Review of a skilled nursing evaluation dated 1/18/25 showed the resident had edema. The resident had +2 pitting edema to the right and left lower legs. b. Review of a skilled nursing evaluation dated 1/19/25 showed the resident had +1 pitting edema to the left lower leg and +2 pitting edema to the right lower leg. c. Review of skilled nursing evaluations dated 1/20/25 and 1/21/25 showed the resident had +1 pitting edema to the left lower leg. d. Review of a wound evaluation dated 1/21/25 showed the resident had a…

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, staff and family interviews, and review of policies and procedures, the facility failed to ensure care was provided in accordance with physician orders and professional standards for non pressure-related wounds for 2 of 3 sample residents (#4, #7) reviewed for wounds. The findings were: 1. Review of the 1/16/25 admission MDS assessment showed resident #4 had diagnoses including heart failure and diabetes mellitus and did not have any wounds. The following concerns were identified: a. Review of a wound evaluation dated 1/21/25 showed the resident had a venous wound on the left foot which was treated with Unna boots [type of compression bandage] and Coban. The evaluation was signed by a physical therapist. b. Review of a wound evaluation dated 1/28/25 showed the venous wound on the left foot remained and was being treated with Unna boots and Coban. The evaluation was signed by a physical therapist. c. Review of wound evaluation dated 2/4/25 showed the venous wound on the left foot remained. The treatment was changed to Cleanse with wound cleanser, apply…

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 and family interview, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 3 sample residents (#5) reviewed for medications. Resident #5 received a drug without adequate indication for its use. The findings were: 1. Review of the 2/9/25 admission MDS assessment showed resident #5 had diagnoses which included history of falling and unspecified pain. The assessment further showed the resident did not have pain during the look-back period. Review of the original admission orders dated 2/3/25 showed an order for Tramadol 50 milligrams (mg), 1 tab, every 6 hours as needed [PRN] for pain. The instructions further read pt normally takes 1 tab at bedtime, but frequency was increased after a fall about a week prior to 1/28/25 admit to every [sic] 6 hours PRN. The following concerns were identified: a. Review of the February MAR showed the Tramadol order was transcribed as 50 mg every 6 hours. The order was put in as a routine order, and not as a PRN order. The order was in place until 2/14/25 when it was changed 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, resident representative and staff interview, review of grievance logs, and policy and procedure review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 4 sample residents (#1). The following concerns were identified: 1. Review of the quarterly minimum data set (MDS) assessment dated [DATE] showed resident #1 had a brief interview for mental status (BIMS) score of 10 out of 15, which indicated s/he had moderately impaired cognition, and diagnoses which included Alzheimer's dementia. The social services assessment note dated 8/5/24 showed the residents hearing was marked as highly impaired. 2. Review of a care conference note dated 9/14/23 showed resident #1's family had voiced concerns about his/her missing hearing aids. 3. Review of facility grievance logs showed no further documentation in relation to the missing hearing aids. 4. Review of the care plan last updated 1/12/25 showed the resident had difficulty hearing related to advanced age.…

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, and staff interview, the facility failed to ensure the comprehensive care plan was implemented for 1 of 3 sample residents (#1) reviewed for care plans. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 10 out of 15, which indicated s/he had moderately impaired cognition, and diagnoses which included Alzheimer's dementia. The social services assessment note dated 8/5/24 showed the resident's hearing was marked as highly impaired. 2. Review of the care plan last updated 1/12/25 showed the resident had difficulty hearing related to advanced age. Further review showed the intervention was to ensure hearing aid(s) were in place. 3. Review of the resident's medical record and ADL tasks performed by the CNA staff dated 12/16/24 to 1/14/24 showed the resident was marked as not owning hearing aids. 4. Observation of the resident on 1/15/25 at 3 PM showed s/he was not wearing hearing aids. 5. Interview 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.

Based on observation, staff interview, manufacturer's instructions review, facility cleaning schedule review, facility policy and procedure review, and 2022 FDA Food Code review, the facility failed to ensure a sanitary environment in 1 out of 1 food preparation area (kitchen). The census was 74. The findings were: 1. Regarding unsanitary items in the kitchen preparation area: a. Observation on 6/10/24 at 1:40 PM during the initial brief tour showed a non-working hand washing sink in the dishwashing room. The drain pipe was disconnected and lying on the floor under the sink, with the water line still connected, and the ability to be turned on. Further observation showed a bucket of standing water under the sink to catch the water and two containers of hand sanitizer on the sink. b. Observation on 6/10/24 at 1:40 PM showed the floor under the dishwasher was dirty with grime, food particles, and hard water build-up on the floor and pipes. c. Observation on 6/12/24 at 10:07 AM showed the cleaning schedule was posted on the wall in the kitchen with no initials demonstrating cleaning as…

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 ensure a licensed administrator was responsible for the management of the facility. The census was 74. The findings were: 1. Interview with the facility administrator on 6/13/24 at 10:23 AM confirmed she did not live in the same town the facility was located. She revealed she communicated with the facility via email and phone calls and she confirmed she was unable to work on premise due to be employed with another agency in the town where she lived. Further interview confirmed her other employment requirements prevented her from being on-site at the facility and she revealed she had never been to the facility. 2. Observation between 6/10/24 and 6/13/24 showed the identified facility administrator was not present, on the premises, during the survey. Further observation throughout the survey showed the unlicensed administrator in training occupied the administrator's office and performing the management functions. 3. Interview with the DON and administrator in training on 6/10/24 at 1:41 PM revealed the facility…

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, staff interview, and review of the dishwasher temperature log sheets, manufacturer's instructions and the 2022 FDA Food code, the facility failed to ensure essential equipment was in safe operating condition in 1 of 1 food preparation areas (kitchen). The census was 74. The findings were: 1. Observation on 6/10/24 at 1:40 PM showed the facility used an Ecolab ES-4000 chemical sanitizing low temperature dishwasher. The temperature of the water was to be monitored at breakfast, lunch and dinner. Review of the Ecolab dishwasher manufacturer's instructions showed the minimum temperature of the wash and rinse water was to be 120 degrees Fahrenheit (F), with a recommended temperature of 140 degrees F. Review of the dish room temperature log shows that temperature of the wash water should be at 120 degrees F, and if not in range to let management know. The following concerns were identified: a. Observation on 6/12/24 at 10:21 AM showed dietary aide #1 washing and sanitizing dishes in the Ecolab ES4000 dishwasher. Dietary aide #1 revealed the temperature of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy and procedure review, the facility failed to ensure infection prevention guidelines were followed during meal service for 1 of 2 dining areas (sunflower). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had short-term memory and long-term memory impairment and had diagnoses which included diabetes mellitus, non-Alzheimer's dementia, and dysphagia. Further review showed the resident required set-up or clean-up assistance with eating. Review of the nutrition care plan last revised on 1/3/24 showed interventions which included staff provide cues and encouragement, physical assistance as needed. The following concerns were identified: a. Observation in the sunflower dining room on 6/10/24 beginning at 4:42 PM showed a dietary staff member was passing meal trays. At that time, an unidentified resident was attempting to reposition resident #36 to a table for dinner, where his/her meal was on the table. Resident #36 began…

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 review of beneficiary protection notice information, staff interview, and policy and procedure review, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (NOMNC) and the Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) forms were issued to the resident or the resident's representative in a timely manner for 1 of 3 sample residents (#76) reviewed. The findings were: 1. Review of the SNF Beneficiary Protection Notification Review form completed by the facility showed resident #76 had a Medicare Part A stay that started on 12/29/23 with the last covered day of Part A services on 3/12/24. The following concerns were identified: a. Review of the medical record showed no evidence a SNF ABN or NOMNC form was completed at the end of part A services. b. Interview with the business office manager on 6/12/24 at 5:52 PM revealed the resident should have been issued the notices; however, she was unable to find evidence the notices were issued. 2. Review of the policy titled Advance Beneficiary Notice provided by the facility 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 medical record review, and staff interview, the facility failed to ensure a pre-admission screening and resident review (PASARR) Level II was performed for 1 of 3 sample residents (#54) with a qualifying diagnosis. The findings were: 1. Review of the 3/27/24 quarterly MDS assessment showed resident #54 had a brief interview for mental status (BIMS) score of 8, which indicated moderate cognitive impairment, and had diagnoses which included anxiety disorder and post-traumatic stress disorder. The following concerns were identified: a. Review of a PASARR level I assessment completed on 8/3/23 showed the resident had post-traumatic stress disorder listed as primary psychiatric diagnosis. Further review showed the resident was indicated as categorically appropriate for convalescent care after acute hospital stay, not to exceed 120 days, an individual Level II determination will be required on the 120th day if client stay will be extended. Review of the resident's medical record showed no evidence a PASARR level II was completed. b. Interview with the DON on 6/11/24 at 4:58 PM…

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, staff interview, and policy and procedure review, the facility failed to ensure residents received assistance with activities of daily living for 1 of 4 sample residents (#36) reviewed during dining. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had short-term memory and long-term memory impairment and had diagnoses which included diabetes mellitus, non-Alzheimer's dementia, and dysphagia. Further review showed the resident required set-up or clean-up assistance with eating. Review of the nutrition care plan last revised on 1/3/24 showed interventions which included staff provide cues and encouragement, physical assistance as needed. The following concerns were identified: a. Observation in the sunflower dining room on 6/10/24 beginning at 4:42 PM showed a dietary staff member was passing meal trays. At that time, an unidentified resident was attempting to reposition resident #36 to a table for dinner, where his/her meal…

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, staff interview, policy and procedure, and manufactory recommendation review the facility failed to ensure expired medication were not available for use in 1 of 3 medication storage units (200 hall medication cart). The findings were: 1. Observation of the 200-hall medication cart on [DATE] at 10:35 AM with RN #1, showed one insulin Aspart flex pen 100 units per milliliter (u/ml) and one Basaglar (insulin glargine) injection 100 u/ml with no expiration dates. 2. Interview with the RN #1 on [DATE] at 10:35 AM confirmed the medication was for resident use, and revealed the insulin pens were to be dated when taken out of the refrigerator. 3. Interview with the DON on [DATE] at 12:52 PM revealed it was the facility expectation for staff to put an open date on the insulin pens. Further, she stated the nurse informed her the observed pens were not labeled with an open or expiration date. 4. Review of policy Medication Administration dated [DATE] showed .13. Identify expiration date. If expired,…

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 review of personnel records, staff interview, and medical record review, the facility failed to ensure the director of nursing was licensed by the State of Wyoming before providing nursing care to facility residents for 5 of 13 (#1, #2, #3, #4, #5) residents reviewed. The facility census was 74. The findings were: 1. Review of the former DON's personnel record showed she was hired on 3/11/24. There was no evidence the former DON had a valid Wyoming nursing license upon hire. The following concerns were identified: a. Review of the medical record for resident #1 showed an Abnormal Involuntary Movement Scale (AIMS) assessment was completed by the former DON on 3/19/24. b. Review of the medical record for resident #2 showed an Alert Charting Note had been completed by the former DON on 3/22/24. c. Review of the medical record for resident #3 showed a Braden Scale (assessment used for predicting pressure sore risk) was completed by the former DON on 3/19/24. d. Review of the medical record for resident #4 showed a medication reconciliation form had been completed by the former…

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, and policy and procedure review, the facility failed to ensure residents received necessary services to maintain good personal hygiene for 2 of 5 sample residents (#1, #3). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 9 out of 15 (moderately cognitive impairment), and required extensive assistance with mobility, dressing, toileting, and hygiene. Review of the care plan last revised on 1/26/24 showed the resident had ADL self-care performance deficit and needed assistance with self care tasks that included bathing. The resident preferred showers on Tuesdays and Fridays. The following concerns were identified: a. Review of January 2024 bathing record showed from 1/19/24 through 1/26/24 the resident went 5 days without a bath/shower. On 1/23/24 the staff marked the bath/shower as Not Applicable. b. Review of February 2024 bathing record showed from 1/30/24 through 2/9/24 the resident…

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 compliant investigation review, the facility failed to ensure residents received care according to professional standards for 1 of 5 sample residents (#1). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 9 out of 15 (moderately cognitive impairment), and required extensive assistance with mobility, dressing, toileting, and hygiene. Diagnoses included Diabetes Mellitus, depression, chronic inflammatory demyelinating polyneuritis, cirrhosis of liver, muscle weakness lipodystrophy, secondary throbocytopenia. The following concerns were identified: a. Review of the physician orders showed start date of 9/1/20 for Blood Sugar (BS) over 400 milligrams per deciliter (mg/dl) call medical director (MD). Below 60 mg/dl call MD. b. Review of the January 2024 medication administration record showed on 1/18/24 at 10:39 AM the BS reading was 452. c. Review of the progress notes failed to show the MD was…

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 resident representative interview, staff interview, medical record review, and policy and procedure review the facility failed to ensure residents were allowed visitation for 1 of 6 sample residents (#2). The findings were: 1. Review of the medical record for resident #2 showed the resident re-admitted to the facility with orders for comfort focused care on 7/25/23 and an allegation of abuse by family members was reported on 7/29/23. Further review showed the resident was evaluated by hospice on 7/30/23 and discharged from the facility on 7/31/23. Review of a Durable Power of Attorney and Authority to Access Health Information dated 11/2/15 identified the resident's grandson as the durable power of attorney. The following concerns were identified: a. Interview with the social services director on 8/3/23 at 10:19 AM revealed the grandson visited the resident on 7/29/23 and he was told family was not able to visit the resident due to an ongoing investigation and the social services director notified local law enforcement. The social services director stated the grandson left…

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 review of investigation documentation, resident representative and staff interview, medical record review, and policy and procedure review, the facility failed to ensure a thorough investigation was performed for 1 of 2 sample residents (#2) reviewed for allegations of abuse. The findings were: 1. Review of investigation documentation provided by the social services director on 8/3/23 showed an allegation of abuse was received from the facility's compliance hotline on 7/29/23 at 11:35 AM. Review of a Skin-Weekly Head to Toe Skin Checks dated 7/25/23 and timed 11:21 PM showed resident still has many bruises on arms and legs where [s/he] bumps them on things and falls. The following concerns were identified: a. Interview with the resident's grandson on 8/3/23 at 12:43 PM revealed after attempting to advocate for the resident and a stern conversation with a certified nurse aide (CNA), an allegation of abuse was made toward two members of his family. He stated he was not part of the investigation. b. Interview with the facility administrator on 8/3/23 at 1:35 PM confirmed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide a written transfer notice to the resident and/or the resident's representative for 3 of 6 sample residents (#6, #47, #51) who were hospitalized . The findings were: 1. Review of nursing notes showed on 2/3/23 resident #51 was found on the floor and told the facility s/he fell. The resident was sent to the emergency room. Further review of nursing notes showed the resident returned from the hospital on 2/9/23. Review of the hospital discharge summary showed the resident was admitted to the hospital on [DATE] and discharged back to the facility on 2/9/23. The following concerns were identified: a. Review of the medical record showed no evidence a written transfer notice was provided to the resident or the resident's representative. b. Interview with the administrator on 3/22/23 at 5:10 PM confirmed the facility could not provide evidence of a transfer notice for this resident's hospitalization. 2. Review of the medical record for…

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 review, the facility failed to provide written notice of the bed-hold policy to the resident and the resident's representative for 3 of 6 sample residents (#6, #47, #51) who were hospitalized . The findings were: 1. Review of nursing notes showed on 2/3/23 resident #51 was found on the floor and stated s/he fell. The resident was send to the emergency room. Further review of nursing notes showed the resident returned from the hospital on 2/9/23. The following concerns were identified: a. Review of the medical record showed no evidence written notice of the bed-hold policy was provided to the resident or the resident's representative. b. Interview on 3/22/23 at 5:10 PM with the administrator confirmed the facility did not have documentation pertaining to the bed-hold notice for this resident's hospitalization. 2. Review of the medical record for resident #47 showed the resident was sent to the hospital on 8/22/22 the resident was sent to the hospital.…

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, staff interview, and policy review, the facility failed to ensure a person-centered care plan was developed for 4 of 27 sample residents (#2, #21, #60, #76). The findings were: 1. Review of the 1/18/23 quarterly MDS assessment showed resident #2 had diagnoses that included non-Alzheimer's dementia, anxiety disorder and depression. The resident received an antianxiety medication and an antidepressant medication on 7 days during the look-back period. Review of the physician orders showed citalopram (antidepressant) 20 mg everyday (ordered 11/3/22), buspirone (antianxiety)10 mg 3 times per day (ordered 10/22/22) and alprazolam (antianxiety) 0.25 mg as needed every 6 hours (ordered 9/14/22). The following concerns were identified: a. Review of the care plan provided by the facility on 3/22/23 at 9:20 AM showed the resident received Buspirone for anxiety. The care plan listed the target behaviors as Anxiety, verbal aggression, restlessness. Anxiety was not further defined and the plan lacked specific behaviors that staff could monitor. b. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were free from unnecessary medications for 7 of 8 residents (#2, #19, #21, #24, #46, #76, #77). The findings were: 1. Review of the 2/8/23 quarterly MDS assessment for resident #46 showed the resident had diagnoses which included anxiety, depression, and manic depression (bipolar depression). Review of March 2023 MAR showed the resident received divalproex sodium (anti-convulsant) 500 mg in the morning and at bedtime, with an order date 7/23/21, trazodone (antidepressant) 100 mg at bedtime, with an order date 12/3/21, and Lexapro (antidepressant) 10 mg daily, with an order date 12/13/21. The following concerns were identified: a. Review of the Psychotropic Medication Management Review dated 12/13/22 showed the resident was stable with no changes. Interview on 3/23/23 at 9:29 AM with the social services director confirmed neither a GDR nor contraindication statement was done. b. Review of the 9/23/22 annual…

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, review of the menus, production sheets, and diet order reports, and staff interview, the facility failed to ensure the menu was followed during 1 of 1 observation of trayline service. The findings were: 1. Review of the daily spreadsheet menu and production sheet for the evening meal on 3/22/23 revealed the regular diet consisted of sweet and sour chicken, steamed white rice, and stir fry vegetable blend. Further review showed the mechanical soft diet was supposed to have ground sweet and sour chicken minus the tomato and pineapple and seasoned broccoli instead of the stir fry vegetables. The pureed diet was supposed to have pureed sweet and sour chicken minus the pineapple and pureed seasoned broccoli instead of the stir fry vegetables. The following concerns were identified: a. Observation on 3/22/23 at 3:54 PM showed dietary aide #1 was dishing up resident meals at the steam table. Further observation showed residents with mechanical soft diets (residents #4, #67, #76, #82) received ground chicken (with no tomato and pineapple). However, the dietary aide…

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, staff interview, and policy and procedure review, the facility failed to ensure medications were not expired for 1 of 4 medication storage units ( 400 hall medication cart). The findings were: 1. Observation on [DATE] 9:30 AM of the 400 hall medication cart with MAC #1 showed the following concerns: a. One insulin glargine 100 unit/ milliliter flex pen without an open date. b. One insulin Lispro 100 unit/milliliter kwik pen without an open date. 2. Interview with the MAC on [DATE] at 9:30 AM revealed the medications were for resident use, and would be administered as ordered. She confirmed the insulins were not dated and she was not sure of the open date. She revealed the label on the pens showed the insulins would expire in 2024. 3. Interview with the DON on [DATE] at 11:55 AM confirmed it was the facility expectation for insulin pens to be dated with an open date when they come out of the refrigerator. 4. Reviewed of the policy and procedure Storage of Medications hand delivered by 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.