Summit Ridge Skilled Nursing & Rehabilitation
1108 Birch Street, Douglas, WY 82633 · For profit - Limited Liability company · 60 certified beds · (307) 358-3397 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0606) — most recent Sep 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- it has 2 actual-harm citations
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $34,646 in federal fines (most recent 2025-09-17)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.0% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.8% | 5.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.9% | 1.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.9% | 3.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 16.1% | 6.5% | 6.5% | worse |
| Long-stay residents who were physically restrained | 1.3% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 3.2% | 4.7% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 18.5% | 15.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.4% | 15.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 85.0% | 94.3% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 6.6% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.5% | 22.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 21.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.8% | 77.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 19.3% | 18.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 19.3% | 16.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.24 | 1.29 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.48 | 2.27 | 1.80 | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 26 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.1%CMS range 30.4–56.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 6.7–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 34.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.3–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.33 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 46.0 residents a day — about 77% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.53 on weekdays — 16% thinner on weekends. RN hours go from 0.79 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2025-09-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident representative and staff interview, facility investigation review, and policy and procedure review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 4 sample residents (#2, #4) reviewed for abuse. This failure resulted in actual harm to resident #2 and resident #4. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and had diagnoses which included dementia, anxiety disorder, and hypertension. The following concerns were identified:a. Review of the facility investigation report dated 1/21/25 and timed 5:58 PM showed on 1/21/25 at 5:22 PM resident #3 grabbed resident # 4 by the arm while attempting to take his/her food tray. b. Review of a progress note for resident #4 dated 1/21/25 and timed 6 PM showed a CNA had observed resident #3 attempting to take a dinner tray from resident #4 and…
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.
- Actual harm · G2024-11-15 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 2 of 4 residents (#4, #97) reviewed for behavioral and emotional needs. This failure resulted in actual harm to resident #97. The findings were: 1. Review of the 7/17/24 MDS discharge assessment for resident #97 showed s/he was admitted to the facility on [DATE] and was discharged to a short-term general hospital on 7/17/24 with a return to the facility not anticipated. Review of the 4/23/24 quarterly MDS assessment showed the resident had diagnoses which included non-traumatic brain dysfunction and non-Alzheimer's dementia. Further review showed the resident had a staff assessment for mental status which indicated moderate cognitive impairment, disorganized thinking which fluctuated in severity, exhibited verbal behavioral symptoms directed towards others 1 to 3…
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.
- Potential for harm · E2026-06-18 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, and policy review, the facility failed to ensure comfortable and safe temperature levels between the temperature range of 71 to 81 degrees F, in 1 of 2 dining areas (main dining room). The census was 49. The findings were: 1. Interview with Resident #35 on 6/15/26 at 4:11 PM revealed the temperature was sometimes cold, especially in the dining room. S/he revealed the facility ran the air conditioner all the time in the dining room. 2. Interview with Resident #2 on 6/15/26 at 4:02 PM revealed the dining room was cold and facility staff had to provide something on his/her shoulders during meals. 3. Interview with 6 residents during the resident council meeting on 6/16/26 at 10:29 AM revealed the dining room and hallways were always cold. 4. Observation on 6/15/26 at 5:07 PM showed the main dining room felt cold in temperature. Observation showed 9 residents in the dining room at that time, 1 was wearing a coat, 1 had a blanket wrapped around his/her shoulders, and 2 residents had blankets on their laps. 5. Observation on 6/17/26 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.
- Potential for harm · Dcited before2026-04-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, and staff and resident interviews, the facility failed to ensure timely activities of daily living (ADL) care for dependent residents in 1 of 4 sampled residents (#3) reviewed for ADL care. The findings were:1.Review of the 4/14/26 cognitive evaluation showed resident #3 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of a provider note dated 4/21/26 showed the resident required assistance with personal cares, was not ambulatory, and was unable to perform ADL's independently due to a recent above the knee amputation. Review of the care plan dated 4/13/26 showed the resident was dependent upon staff for incontinence care and had interventions which included .Provide incontinence care after each incontinent episode. and .ADL needs will be met each day. The following concerns were identified:a. Observation on 4/28/26 at 1:56 PM showed resident #3's call light was on. At 1:58 PM an unidentified staff member entered the room and was told by the resident that two staff members were required 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.
- Potential for harm · Dcited before2025-09-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident, resident representative, and staff interview, medical record review, and policy review, the facility failed to ensure that a resident who required assistance for activities of daily living (ADL) received appropriate services to maintain grooming and hygiene for 1 of 3 sampled residents (#1) reviewed for ADLs. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included hypertension, diabetes mellitus, and arthritis. Further review showed the resident required partial to moderate assistance with bathing and was wheelchair bound. Review of the resident's care plan dated 8/26/25 showed that the resident had alterations in ADL function secondary to weakness and pain and required assistance completing ADL task's The following concerns were identified:a. Interview with the resident on 9/16/25 at 11:33 AM revealed 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.
- Potential for harm · D2025-01-03 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of resident trust fund account statements, staff interview, and Medicaid eligibility review, the facility failed to ensure residents' right to manage their personal funds for 2 of 13 (#1, #2) sample residents with accounts at the facility. The findings were: 1. Review of the resident trust fund account statement for resident #1, with a start date of 11/15/22 showed the resident had a balance of $50.02 in the account on 4/30/24. The following concerns were identified: a. On 5/3/24 the facility received a payment of $1,267.00 from the Social Security Administration (SSA) which was deposited into the resident's account. On 5/7/24 a payment was made to the facility for $1,317.02 which left a zero balance in the resident's account. There was no evidence the resident had received his/her $50 personal needs allowance. b. On 6/3/24 the facility received a payment of $1,267.00 from the SSA which was deposited into the resident's account. On 6/3/24 a payment was made to the facility for $1,270.70 which left a balance of minus $.70 in the resident's account. There was no…
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.
- Potential for harm · Dcited before2025-01-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, facility incident investigation review, facility performance improvement plan review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 5 (#3) residents involved in a resident-to-resident altercations. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of [DATE]. The findings were: 1. Review of the [DATE] quarterly MDS assessment for resident #3 showed the resident had short-term and long-term memory problems and diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, and dementia. The resident did not exhibit any behaviors, rejection of care, or wandering during the look-back period. The following concerns were identified: a. Review of a [DATE] and timed 9:57 PM progress note showed the resident was sitting at a table in the dining area when a resident (identified as resident #4) walked…
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.
- Potential for harm · D2025-01-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the facility's abuse investigation forms, State Survey Agency incident database review, policy and procedure review, and staff interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of the reasonable suspicion of a crime in for 2 of 5 sample residents (#3, #7) reviewed for allegations of abuse. The findings were: 1. Review of the facility's policy Abuse, Neglect, and Exploitation, implemented on 5/30/23, showed .Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The following concerns were identified: a. Review of the facility's Resident Abuse Investigation Report Form showed a resident-to-resident altercation occurred on 12/9/24 at 6:55 PM and was reported to facility administration at 7…
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.
- Potential for harm · F2024-11-15 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on nursing staff schedule review and staff interview, the facility failed to have a system in place to document licensed nurses in the facility on a 24-hour basis. The findings were: 1. Review of the PBJ (payroll-based journal) Staffing Data Report for July 1 through [DATE] showed the following concerns: a. The PBJ showed the facility failed to provide nursing coverage 24 hours/day on 7/21, 7/23, and 7/30. b. Review of the working schedule showed on 7/21 the DON was on duty for 12 hours starting at 6 AM. On 9/10, 9/23, and 9/30 the DON was shown as working a 12-shift starting at 6 PM. The other days noted on the PBJ were covered by nursing staff. 2. Review of the PBJ Staffing Data Report for October 1 through December 31, 2023 showed the following concerns: a. The PBJ showed the facility failed to provide nursing coverage 24 hours/day on 10/1, 10/8, 10/29, 11/23, 12/2, 12/3, and 12/9. b. Review of the working schedule showed on 10/29 the DON worked a 12-hour shift starting at 6 AM. On 11/23 the DON worked…
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.
- Potential for harm · F2024-11-15 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview, the facility failed to ensure the dietary manager met the required qualifications. The facility census was 43. The findings were: 1. Interview with the dietary manager on 11/14/24 at 2:08 PM revealed she had not completed the Certified Dietary Manager coursework; however, planned to have it done soon. Further interview with the dietary manager revealed the facility had a dietician on site every Tuesday for 8 hours.
- Potential for harm · Fcited before2024-11-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and policy and procedure review, the facility failed to implement a water management program to prevent, detect, and control the risk of water-borne pathogens. In addition, the facility failed to conduct an annual review of its infection prevention and control program (IPCP). The census was 43. The findings were: 1. Review of the facility's Infection Prevention and Control Program policy showed it was implemented on 5/22/23. There was no evidence the facility had conducted an annual review of its IPCP and updated their program, if necessary. 2. Review of the 5/22/23 IPCP policy showed .17. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with DCC's water systems. c. The Maintenance Director along with the Safety Committee serves as the leader of the water management program. Review of the 5/2021 Legionella Surveillance policy showed .2. In the absence of Legionella infections for 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.
- Potential for harm · Dcited before2024-11-15 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay for 1 of 4 resident-initiated discharges (#97) reviewed. The findings were: Review of the 7/17/24 MDS discharge assessment for resident #97 showed s/he was admitted to the facility on [DATE] and was discharged to a short-term general hospital on 7/17/24 with a return to the facility not anticipated. Further review of the medical record showed no evidence a discharge summary had been completed. Interview on 11/14/24 at 5:15 PM with the NHA confirmed the discharge summary had not been completed.
Show the remaining 16 citations
- Potential for harm · D2024-11-15 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, policy and procedure review, and staff interview, the facility failed to ensure bed rails were evaluated for safety on a regular basis for 1 of 2 residents (#15) reviewed with bed rails. The findings were: 1. Observation on 11/12/24 at 1:15 PM showed resident #15 had an assist bar, bilaterally, at the head of the bed. Review of the resident's medical record showed the last assist bar evaluation was completed on 4/6/21. Interview with the MDS coordinator on 11/13/24 at 4:20 PM revealed safety assessments should be conducted annually and confirmed no further documentation was available. 2. Review of the 2/13/23 Use of Assistive Devices policy showed .2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care 4. DCC staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, safety evaluations, set up assistance, supervision, or physical…
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.
- Potential for harm · D2024-11-15 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (#98) reviewed for dementia care. The findings were: 1. Review of the 9/6/24 quarterly MDS assessment for resident #98 showed the resident was admitted to the facility on [DATE] and had diagnoses which included alcohol dependence with alcohol-induced persisting dementia, anxiety disorder, and depression. The resident had a BIMS score of 4 out of 15 indicating severe cognitive impairment. Further review showed the resident was coded as being administered an antidepressant. A resident-initiated transfer to another long-term care facility occurred on 9/9/24. The following concerns were identified: a. Review of the Event Forms from 8/5/24 through 9/5/24 showed the resident had a resident-to-resident altercation with aggressive/combative behaviors on 5/10, 5/18,…
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.
- Potential for harm · D2024-11-15 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure medically related social services were provided for 1 of 1 sample residents (#4) reviewed with a PASRR (Preadmission Screening and Resident Review) Level II. The following concerns were identified: 1. Review of the 9/13/24 quarterly MDS showed resident #4 was re-admitted from the hospital to the facility on 3/1/24 and had diagnoses which included cerebrovascular accident, non-Alzheimer's dementia, depression and bipolar disorder. The resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Further review showed the resident did not exhibit physical or verbal behavioral symptoms or rejection of care. Review of the resident's care plan dated 3/22/23 showed When I have suicidal ideations or similar behaviors my staff will try to redirect me, they may offer me to call my counselor that I see or my family. They may take me to the common area or dining room to visit and interact with people and so my staff can ensure my safety. Further…
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.
- Potential for harm · E2023-08-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of the 2022 U.S. Public Health Service Food Code, the facility failed to ensure proper hand hygiene during 1 of 1 food preparation observations. The census was 42. The findings were: 1. Observation on 8/29/23 at 11:45 AM showed cook #1 and dietary aide #1 were preparing to serve the noon meal. Dietary aide #1 was wearing gloves and performing various tasks throughout the kitchen. At 11:56 AM dietary aide #1 was observed placing his gloved hand into a pitcher of ice, transferred the ice to a beverage cup, added iced tea to the container, and placed the cup on a tray to be delivered to a resident. At 12:22 PM the dietary aide (wearing the same gloves) again placed his gloved hand into the pitcher of ice, transferred the ice to a beverage cup, added liquid to the cup, and then gave the cup to a CNA to deliver to a resident. 2. Interview with the certified dietary manager on 8/29/23 at 2:36 PM revealed it was her expectation staff members use a scoop when handling ice. 3. Review of the 2022 U.S. Public Health Service Food Code 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.
- Potential for harm · D2023-08-30 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
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 (#17) reviewed. The findings were: 1. Review of the SNF Beneficiary Protection Notification Review form completed by the facility showed resident #17 had a Medicare Part A stay that started on 12/27/22 with the last covered day of Part A services on 2/19/23. The following concerns were identified: a. Review of the NOMNC and SNF-ABN forms showed the resident's representative signed the forms on 3/6/23. b. Review of the facility's documentation showed the NOMNC and SNF-ABN forms were mailed to the resident's representative via certified mail on 3/1/23. There was no documentation the resident's representative had been contacted prior to the last day of Medicare Part A coverage. c. 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.
- Potential for harm · D2023-08-30 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
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 a restraint was the least restrictive alternative, used for the least amount of time, and failed to inform and obtain consent from the resident or the resident's representative for the use of the restraint for 1 of 2 sample residents (#31) with restraints. The findings were: 1. Review of the 7/12/23 admission MDS assessment showed resident #31 was admitted to the facility on [DATE] with diagnoses which included hip fracture and dementia. The resident was determined by staff assessment to be severely cognitively impaired and required the extensive assistance of two or more staff for transfers. In addition, the resident was coded as using a physical restraint in the resident's chair to prevent the resident from rising on a daily basis. Review of the 7/12/23 care area assessment (CAA) for physical restraints showed resident has dementia and weight bearing restrictions. [S/he] does 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.
- Potential for harm · Dcited before2023-08-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, manufacturer recommendations, and policy and procedure review, the facility failed to develop and implement resident care plans related to pressure-relieving devices for 2 of 4 residents reviewed (#10, #14) for pressure injuries. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had diagnoses which included hip fracture, obesity, and weakness, and was at risk for pressure ulcer development. Further review showed the resident required extensive physical assistance of 2 or more people for bed mobility and toilet use, extensive physical assistance of 1 person for dressing and personal hygiene, and transfers did not occur during the look-back period. Review of a Wound Management Detail Report showed on 8/28/23 the resident had a stage 2 wound which measured 0.2 centimeters (cm) by 0.3 cm which was very superficial. Further review showed the wound was identified on 8/21/23. The following concerns were identified:…
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.
- Potential for harm · Dcited before2023-08-30 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
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 complete a discharge summary which included a recapitulation of the resident's stay for 1 of 1 resident (#42) reviewed for discharge to the community. The findings were: 1. Review of the medical record for resident #42 showed s/he was admitted to the facility on [DATE] for rehabilitation following a cerebral vascular accident. The resident was discharged to the community on 7/18/23. Further review of the resident's medical record showed no evidence a discharge summary had been completed. Telephone interview with the DON on 8/30/23 at 9:50 AM confirmed the discharge summary had not been completed. 2. Review of the Transfer and Discharge (including AMA) policy implemented on 7/18/23 showed .14. b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nursing department at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes,…
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.
- Potential for harm · D2023-08-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, manufacturer recommendations, and policy and procedure review, the facility failed to ensure pressure-relieving devices to prevent pressure injuries or deterioration of pressure injuries were used appropriately for 2 of 4 residents reviewed (#10, #14) for pressure injuries. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had diagnoses which included hip fracture, obesity, and weakness, and was at risk for pressure ulcer development. Further review showed the resident required extensive physical assistance of 2 or more people for bed mobility and toilet use, extensive physical assistance of 1 person for dressing and personal hygiene, and transfers did not occur during the look-back period. Review of a Wound Management Detail Report showed on 8/28/23 the resident had a stage 2 wound which measured 0.2 centimeters (cm) by 0.3 cm which was very superficial. Further review showed the wound was identified 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.
- Potential for harm · Dcited before2023-08-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure infection prevention and control practices were implemented for 1 of 3 residents (#37) reviewed for wound care. The findings were: 1. Review of the 8/11/23 quarterly MDS assessment for resident #37 showed the resident had a BIMS score of 11 out of 15, which indicated the resident had moderately impaired cognition, and diagnoses which included a wound infection, methicillin resistant Staphylococcus aureus infection (MRSA), and a cutaneous abscess. Further review showed the resident had a surgical wound with an application of a nonsurgical dressing and received an antibiotic 7 days out of the 7-day look-back period. The following concerns were identified: a. Observation on 8/28/23 at 1:50 PM showed the wound care nurse and PTA #1 entered the resident's room wearing gowns, gloves, and masks. During wound care PTA #1 used his gloved hand to remove an old and rolled up dressing from the left side of the resident's back. PTA #1 cleaned the resident's wound, and…
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.
- Potential for harm · D2023-08-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
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 vaccinations were offered and/or administered to 1 of 5 sample residents (#37) reviewed for immunizations. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #37 admitted to the facility on [DATE] and the resident did not receive the influenza or pneumococcal vaccines. Further review showed the resident was offered the vaccinations and declined administration. However, review of the medical record showed no evidence the influenza or pneumococcal vaccinations were offered, accepted/declined, or administered in the facility or community. 2. Interview with the infection preventionist on 8/30/23 at 8:45 AM confirmed there was no evidence the influenza or pneumococcal vaccinations were offered, accepted/declined, or administered in the facility or community. 3. Review of the policy titled Infection Prevention and Control Program dated 5/22/23 showed .7. Influenza and…
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.
- Potential for harm · F2022-08-10 · tag F0886 — failed to test for COVID-19 as required — widespreadPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff vaccination data review, CDC COVID-19 data review, staff COVID-19 testing documentation review, CMS guidance review, staff interview, policy review, and performance improvement plan review, the facility failed to ensure testing of staff for COVID-19 met requirements for 6 of 6 sample staff members (CNA #2, #3, #4, #5; LPN #1; RN #2) with vaccine exemptions. The census was 55. The findings were: Observation upon entrance to the facility on 8/7/22 at 10:41 AM showed a posted sign indicating the COVID-19 positivity rate for the community was high. At that time the DON confirmed there were no active COVID-19 cases in the facility. She further stated that one CNA had tested positive on 7/31/22, had been assigned to work exclusively in the secured unit, and the CNA left the facility upon testing positive. She stated the CNA had not been to any other area of the facility that day. Review of staff COVID-19 vaccine data provided by the facility on 8/7/22 showed 28 staff members out of 68 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.
- Potential for harm · D2022-08-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, and staff interview, the facility failed to ensure the physician or mid-level practitioner was notified concerning a change in condition regarding swallowing issues for 1 of 1 sample residents (#22) reviewed for that issue. The findings were: 1. Review of the 5/13/22 quarterly MDS assessment showed resident #22 had diagnoses which included Alzheimer's dementia and depression. The review showed the resident had a BIMS score of 3 (severe cognitive impairment). The review showed the following regarding swallowing, Holding food in mouth/cheeks or residual food in mouth after meals. Observation of the resident on 8/7/22 at 12:17 PM in the secure unit dining area showed the resident was having difficulty drinking tea and a protein supplement shake, and was intermittently coughing while being assisted by staff. The staff were prompting the resident to swallow. The liquids did not appear to be thickened. Observations on 8/7/22 at 4:28 PM and 4:31 PM showed the resident was in the secure unit dining area, and [s/he] had difficulty with swallowing…
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.
- Potential for harm · D2022-08-10 · tag F0606 — failed to not employ staff found guilty of abuse — isolatedNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — the official record, unedited, may be distressing
Based on employee record review, staff interview, staffing schedule review, and policy and procedure review, the facility failed to ensure the CNA registry was checked prior to resident contact for 1 of 2 CNA records (CNA #1) reviewed. The findings were: 1. Review of the employee record for CNA #1 showed a hire date of 4/15/22. The review showed the CNA registry was not checked for the CNA's status until 8/10/22 (the date the record review took place). Review of staffing schedules showed the CNA had been working independently prior to 8/10/22. Interview with the administrator on 8/10/22 at 10:28 AM confirmed the facility failed to check the CNA registry in a timely manner for CNA #1. 2. Review of the policy titled, Policy on Detecting, Preventing, and Reporting Abuse, Neglect, Mistreatment of Residents or Misappropriation of Resident Property, dated March 2018, showed the following under 'Handout for Abuse Policy', Procedure: 1. All potential employees will be screened to avoid hiring those with a history of abuse .
- Potential for harm · Dcited before2022-08-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and policy and procedure review, the facility failed to ensure resident-specific care plans were implemented for 3 of 16 (#34, #38, #100) residents reviewed. The findings were: 1. Review of the 6/5/22 admission MDS assessment showed resident #34 was admitted with diagnoses that included Alzheimer's disease, altered mental status, weakness, and repeated falls. Review of the current care plan, last revised 6/5/22, showed a problem area related to the resident being . at risk for falls [related to] weakness and history of frequent falls. The following concerns were identified: a. Observation on 8/7/22 at 4:19 PM showed a recliner in the resident's room. It was noted the recliner was elevated off the floor, sitting on top of two 2x4's stacked on top of one another. The boards were screwed into the base of the chair, making it approximately three inches higher off of the floor. Interview with the resident at that time revealed s/he had tipped…
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.
- Potential for harm · D2022-08-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, resident and staff interview, and policy and procedure review, the facility failed to ensure residents were evaluated for potential safety concerns for 1 of 6 (#34) residents reviewed. The findings were: 1. Review of the 6/5/22 admission MDS assessment showed resident #34 was admitted with diagnoses that included Alzheimer's disease, altered mental status, weakness, and repeated falls. Review of the current care plan, last revised 6/5/22, showed a problem area indicating the resident was . at risk for falls [related to] weakness and history of frequent falls. The following concerns were identified: a. Observation on 8/7/22 at 4:19 PM showed a recliner in the resident's room. It was noted the recliner was elevated off the floor, sitting on top of two 2x4's stacked on top of one another. The boards were screwed into the base of the recliner, making it approximately three inches higher off of the floor. The resident stated at that time the chair had been in his/her room since admission. Further, s/he had tipped the chair over due to its…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$34,646 in federal fines across 2 penalties.
- $14,950 — penalty dated 2025-09-17
- $19,696 — penalty dated 2024-11-15
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ROCKY MOUNTAIN CARE — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.0 | -2.0 vs chain |
| Health inspection | 1 of 5 | 2.1 | -1.1 vs chain |
| Staffing | 4 of 5 | 2.9 | +1.1 vs chain |
| Quality measures | 2 of 5 | 4.7 | -2.7 vs chain |
The other 9 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BANGERTE, NATHAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/01/2025 |
| BANGERTER, EDWARD | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/01/2025 |
| BANGERTER, JOHNATHAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/01/2025 |
| DARBY, MEGAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/01/2025 |
| GATHERUM, JASON | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/01/2025 |
| MORRISON, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2025 |
| NEVES, COURTNEY | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/01/2025 |
| SIMMONS, BENJAMIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2025 |
| SNOWBALL, KELLY | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2025 |
| SUMMIT RIDGE OC LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2025 |
| CONNELL, ERIC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2025 |
| LAKE, CRYSTAL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2025 |
| MCMILLAN, KARLI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2025 |
| WINTERHOLLER, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2025 |
| ROCKY MOUNTAIN CARE LLC | Organization | ADP OF THE SNF | since 09/24/2025 |
CMS files one row per role, so the 22 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $252K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Wyoming Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 535040. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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