Mountain View Skilled Nursing Community at WLRC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, facility investigation review, professional standard review, and policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 8 sample residents (#10) reviewed for quality of care. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment, and had diagnoses which included nontraumatic brain dysfunction, schizoaffective disorder, depression and hypertension. Review of the resident's care plan last revised on 3/19/26 showed a history of delirium, cognitive loss, depression and non-compliance with taking medications. Further review showed the resident did not believe s/he had medical issues and s/he did not need medications. The care plan showed nurses were to approach the resident calmly to inform him/her when it was time for his/her medication and if s/he refused,…

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 facility incident report review, state survey agency incident database review, staff interview, and policy and procedure review, the facility failed to ensure timely reporting of allegations of abuse for 2 of 13 sample residents (#1, #2) reviewed for allegations of abuse. The findings were: 1. Review of a facility incident report dated 9/27/25 and timed 4 PM showed resident #1 called resident #2 an asshole and resident #2 threw a cup of juice on resident #1.2. Review of the state survey agency incident database showed the incident was reported on 9/30/25 at 8:12 AM, 3 days after the incident occurred.3. Interview with facility investigator on 10/15/25 at 12:46 PM confirmed the incident was not reported timely. She revealed the incident occurred on a Saturday and at that time, they did not have any staff members who had access to the incident database that worked on the weekends. 4. Review of the facility policy titled Prevention of Resident Abuse, neglect, and Exploitation dated 5/14/25 showed .3. WLRC staff will report the allegation to the Wyoming Healthcare Licensing 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.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to provide a written notice of transfer for 1 of 2 sample residents (#4) reviewed for facility-initiated transfers. The findings were: 1. Review of a 12/16/24 nurse progress note showed resident #4 was transferred to the hospital for an acute change of condition. Further review showed no evidence the facility issued a written transfer notice to the resident or the resident's representative. 2. Interview with the social services director on 1/24/25 at 10:51 AM revealed she was unable to locate the transfer notice. 3. Review of the 10/28/24 Transfer or Discharge; notice of; Appealing and Emergency Discharge policy showed .When a resident is temporarily transferred on an emergency basis to an acute care facility, the Social Worker, designee, or Nurse will provide verbal confirmation of transfer to the resident and family member or legal representative immediately or as soon as practicable. The resident and/or representative will also be notified by the Social Worker or designee in…

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 and procedure review, the facility failed to provide written information on the bed-hold policy for 1 of 2 sample residents (#4) reviewed for facility-initiated transfers. The findings were: 1. Review of a 12/16/24 nurse progress note showed resident #4 was transferred to the hospital for an acute change of condition. Further review showed no evidence the facility issued written information on the bed-hold policy to the resident or the resident's representative at the time of the hospitalization. 2. Interview with the social services director on 1/24/25 at 10:51 AM revealed she was unable to locate the bed-hold notice. 3. Review of the 9/24/24 Bed Hold and Return policy showed .a. Upon admission and prior to any transfer, residents and/or their representatives will be provided written information regarding State and facility bed hold policies, which address holding a resident's bed during periods of absence (hospitalization or therapeutic leave) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to arrange for specialized services to meet the resident's needs as identified on the Preadmission Screening and Resident Review (PASARR) level II for 1 of 2 sample residents (#9) reviewed. The findings were: 1. Review of the 8/8/24 annual MDS assessment showed resident #9 was admitted to the facility on [DATE] from an inpatient psychiatric hospital. The resident was coded as having been evaluated by a Level II PASARR and determined to have a serious mental illness. The resident had a BIMS score of 3 out 15, which indicated severe cognitive impairment, with inattention and disorganized thinking. In addition, the resident had diagnoses which included anxiety disorder, depression, bipolar, and psychotic disorder. Review of the 1/13/23 PASARR Level II Determination Summary Report showed the resident met the state definition of mental illness and recommended rehabilitative services to be provided in the nursing facility to include a minimum of…

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, policy and procedure review, and review of CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 1 of 5 sample residents (#3) reviewed for immunizations. The findings were: 1. Review of the 10/21/24 quarterly MDS assessment showed resident #3 was admitted to the facility on [DATE]. The resident was [AGE] years old. The following concerns were identified: a. Review of Section O of the 10/21/24 quarterly MDS assessment showed the resident's pneumococcal vaccine was not up-to-date and had not been offered. b. Review of the resident's medical record showed no evidence the resident had been previously vaccinated. c. Interview with the DON on 1/24/25 at 12:47 PM confirmed the resident had not been offered the vaccine. 2. Review of the 4/5/22 Vaccination of Residents policy showed All residents will be offered vaccines that aid in preventing infectious disease unless the vaccine…

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, review of policy and procedures, and 2022 FDA Food Code review, the facility failed to ensure a sanitary environment in 2 of 2 food preparation areas (main kitchen, Sunflower cottage). The census was 8. The findings were: 1. Observation in the main kitchen on 10/25/23 at 11:03 AM showed walk-in freezer #2 had a sign posted on the door which said floors may be icy. Continued observation showed ice was built up on the floor, ceiling, and fans throughout the freezer, including on walk ways. 2. Observation on 10/25/23 at 11:05 AM showed the [NAME] dual oven #1 had dirt, grease, debris, and dead flies on the top. Further observation showed 4 additional oven racks were stored on top of the oven. 3. Observation on 10/25/23 11:09 AM showed the [NAME] dual oven #2 had dirt, grease, debris, and dead flies on the top. Further observation showed 3 additional oven racks were stored on top of the oven and the oven was in use. Interview with kitchen staff member #1 confirmed the oven 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 fund account review, staff interview, and facility investigation review, the facility failed to protect the residents' right to be free from misappropriation of resident property by a staff member for 5 of 9 sample residents (#2, #3, #4, #5, #6). Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 9/1/23. The findings were: 1. Review of a facility incident report dated 7/12/23 showed accounting staff identified several receipts for resident item purchases they determined were questionable. The incident report showed all the receipts were provided for residents #2, #3, #4, #5, and #6 by CNA #1. An investigation was initiated and the CNA was placed on leave pending the investigation. The following concerns were identified: a. The incident report showed the facility interviewed the CNA on 7/14/23 at 9:30 AM and the CNA admitted she took money intended for resident purchases and generated the receipts on a computer in her office. The incident report review showed the CNA admitted to taking approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified related to the use of psychotropic medications for 3 of 5 sample residents (#1, #2, #8) reviewed for unnecessary medications. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #1 had diagnoses which included cerebrovascular attack, transient ischemic attack, or stroke, non-Alzheimer's dementia, seizure disorder, traumatic brain injury, and a psychotic disorder other than schizophrenia, physical behavioral symptoms directed toward others which occurred on 1 to 3 days during the look-back period, and verbal behavioral symptoms directed toward others which occurred on 1 to 3 days during the look-back period. Further review showed the resident received antipsychotic medication on an as needed basis since the prior assessment and a gradual dose reduction was attempted on 6/12/23. Review of the physician's orders showed 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.

2. Review of physician orders for October 2022 showed resident #53 had orders for quetiapine (anti-psychotic) 125 mg via g-tube (gastrostomy tube, a type of feeding tube) every day at bedtime for major depressive disorder and unspecified intracranial injury with loss of consciousness, and escitalopram (anti-depressant) 20 mg by mouth every day in the morning for major depressive disorder. Further review showed the resident had diagnoses which included intracranial injury with loss of consciousness, major depressive disorder, epilepsy and epileptic syndromes with complex partial seizures, and dysphagia. Review of the care plan last revised 7/11/22 showed problems which included Behavioral Symptoms: [Resident] has displayed disruptive verbal aggression towards residents and staff. [Resident] has displayed disruptive physical behavior in banging on tables and other objects.[Resident] has displayed frustration by removing [his/her] feeding tube because [s/he] cannot eat orally. Interventions included gently remind [resident] that screaming/ cursing is not appropriate. Record behaviors…

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 and procedure review, the facility failed to provide a written notice of transfer for 1 of 1 sample residents (#57) reviewed for facility-initiated transfers. The findings were: 1. Review of the medical record showed resident #57 was transferred to the hospital on 9/11/22. Further review showed no evidence the facility issued a written transfer notice to the resident or the resident's representative. 2. Interview with the administrator and DON on 10/13/22 at 9:41 AM confirmed the facility did not send written transfer notices to the resident or resident's representative. 3. Review of the policy titled Transfer or Discharge; Notice of; Appealing and Emergency Discharge dated 3/31/22 showed .Emergency Discharge or Transfer .When a resident is temporarily transferred on an emergency basis to an acute care facility the Nurse or Social Worker will provide an Immediate Notice of Transfer or Discharge to the resident and family member or legal representative as soon as practicable .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to provide a written notice of the bed-hold policy for 1 of 1 sample residents (#57) reviewed for facility-initiated transfers. The findings were: 1. Review of the medical record showed resident #57 was transferred to the hospital on 9/11/22. Further review showed no evidence the facility issued a written notice of the bed-hold policy to the resident or the resident's representative. 2. Interview with the administrator and DON on 10/13/22 at 9:41 AM confirmed the facility did not send a written notice of the bed-hold policy to the resident or resident's representative. 3. Review of the facility policy titled Bed Hold and Return dated 3/31/22 showed .1 .a. When hospital transfers occur, the Social Worker (or nurse if Social Worker is unavailable) will provide the resident and/or resident representative a copy of the bed-hold form. b. For an emergency hospital transfer, a copy of the bed-hold form will be sent with the resident and a copy for the resident representative will be sent…

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.

2. Interview with the DON on 10/13/22 at 9:54 AM revealed she expected staff to perform hand hygiene upon entering a resident room and before exiting the room. In addition, staff should prepare supplies prior to the start of care and should don clean gloves after coming in contact with soiled items, prior to touching clean items. Further interview revealed if she observed staff perform incontinence care and touch clean items prior to removing their soiled gloves, she would assign additional education for the staff member to complete. 3. Review of the policy titled Handwashing/Hand Hygiene dated 4/1/22 showed .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. Difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. before 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.