Big Horn Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and guardian interview, the facility failed to provide a notice of transfer/discharge prior to a facility-initiated hospital transfer for 3 of 6 sample residents (#6, #69, #77) and failed to provide written information on the bed-hold policy to the resident or the resident's representative for 1 of 6 sample residents ( #77) reviewed for facility-initiated transfers. In addition, the facility failed to send a copy of the transfer/discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The findings were: 1. Review of the medical record showed resident #6 was transferred to the hospital on [DATE]. Further review showed no evidence the facility had issued a written transfer/discharge notice to the resident and/or the resident representative. There was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. a. Interview with the Regional Clinical Director on 5/7/26 at 11:45 AM confirmed there…

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

Based on observation, medical record review, resident representative and staff interview, and policy review, the facility failed to ensure individual activities of preference were provided to 1 of 3 sample residents (#80) reviewed. The findings were:1. Review of resident #80's care plan initiated on 4/24/26 showed s/he had a diagnosis of Alzheimer's disease, and was at risk for depression and impaired social interaction. Further review showed the resident will participate in social situations, activities of choice . The following concerns were identified: a. Interview with the resident's representative on 5/5/26 at 9:46 AM revealed the resident had not received activities at the facility. She reported the resident needed to stay busy, and s/he was unable to focus due to his/her diagnosis of dementia. She reported when she attempted to talk to activity staff about appropriate activities for the resident, they were always on their way to somewhere else. b. Observations throughout the survey showed the resident wandered in the halls and sat in the front lobby. The resident was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and medical record review, the facility failed to ensure that residents received care that accounted for resident preferences that mitigated triggers for past trauma for 1 of 8 sample residents (#66) reviewed for trauma informed care. The findings were:1.Review of the quarterly MDS assessment dated [DATE] showed the resident had a BIMS score of 13 out of 15 which indicated little to no cognitive impairment, and had diagnoses which included schizophrenia, anxiety, and post-traumatic stress disorder (PTSD).a. Interview with the resident on 5/4/26 at 3:21 PM revealed the s/he had requested to not have men bathe her/him due to PTSD from sexual assault in the past, and s/he has had to remind staff weekly of his/her preference.b. Review of the care plan dated 1/23/26 showed no identification of the resident's preference for female staff only to assist in the areas of personalized care, ADL's and bathing, and mood and behavior, and no identification of triggers for PTSD or…

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 manufacturer's instructions, and facility policy review, the facility failed to ensure a sanitary environment in 1 of 1 kitchen. The findings were: 1. Regarding unsanitary items in the kitchen preparation area: a. Observation on 2/4/26 beginning at 9:15 AM showed the Traulsen refrigerator had visible grime and dried food particles on the surface, and a sticky handle when touched to open. The soap dispenser at the handwashing sink had a dark, reddish build-up on the pump. The ice machine scoop was placed on top of the machine next to packaged hair nets. 2. Regarding food safety: a. Observation on 2/4/26 beginning at 9:15 AM showed undated, unlabeled package of ham was found inside the Traulson refrigerator. The walk-in refrigerator did not show a temperature on the thermostat. A partially uncovered, undated bowl of crushed vanilla wafers was found on a bottom shelf of the walk-in pantry. There were no logs visible for the walk-in refrigerator and freezer. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and resident and resident representative interview, the facility failed to provide a safe, clean, comfortable and homelike environment for 3 of 4 (Secure unit, 100, 400 halls) units reviewed. The findings were:1. Regarding homelike environment:a. Observation throughout the days on 2/4/26 and 2/5/26 showed no washcloths, bath towels. or hand towels in resident rooms on 3 of 4 units. b. Interview with resident representative for resident #1 on 2/5/26 at 10:20 AM revealed there was never any linen in the resident's room to assist with bathing when she visited. c. Interview with the director of housekeeping 2/5/26 at 11:30 AM revealed that clean linen was available in the clean supply storage for staff to stock rooms.d. Interview with RN # 1 on 2/5/26 at 11:45 AM revealed that staff will supply residents with hand towels and clean linen from the clean supply room when needed.e. Interview with the DON on 2/5/26 at 11:15 AM revealed staff were expected to stock resident rooms…

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 staff and family council president interview, and review of family council minutes, the facility failed to provide and support a private meeting space for family council meetings in 1 out of 12 months in the year 2025. Corrective measures were implemented prior to the survey and compliance was determined to be met on 4/29/25. The census was 66. The findings were:1. Interview with the family council president on 2/4/26 at 12:19 PM revealed the facility canceled the family council meeting and did not provide a meeting space for the month of March 2025. She further revealed there was a sign posted on the community board on 3/4/2025 that stated Family council meeting for March will be canceled. Look forward to seeing you in April, contact social services with any questions. S/he was then told by the former activity director that there wouldn't be a meeting in March and there might not be one in April because they were trouble makers. 2. Review of the family council meetings confirmed no meeting occurred in March 2025.3. Review of Family Council meeting minutes provided by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review and policy review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (#3) reviewed for accident hazards. The findings were:1. Review of the 1/2/26 quarterly MDS assessment for resident #3 showed s/he was admitted to the facility on [DATE], had a BIMS score of 11 out of 15, which indicated moderate cognitive impairment, and diagnoses which included Alzheimer's disease, Non-Alzheimer's dementia, and cancer. Further review showed the resident's mood interview revealed the resident had reported feeling down, depressed or hopeless for 12 to 14 days of the 14-day look-back period. The resident was coded as receiving an antipsychotic medication. Review of the resident's progress notes showed the resident reported s/he was going to leave the building. The following concerns were identified: a. Review of the medical record showed the resident's 8/11/25 elopement evaluation score was 0. b. Review of a progress…

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 staff interview, the facility failed to ensure social services were provided to residents by a qualified social worker. The findings were:1.Interview with the SSD on 2/4/26 at 4:40 PM revealed she started the job in October 2025. Further interview confirmed her bachelor's degree was in criminal justice. She reported she reached out to the social worker in another facility if she had any questions, but did not have any regular scheduled meetings with her.2.Interview with the NHA on 2/5/26 at 1:55 PM revealed he assumed the SSD had someone she consulted with between her date of hire and now. Further interview revealed he did not have a facility policy on the required qualifications.

Based on resident and staff interview, medical record review, and facility policy and procedure review, the facility failed to ensure bathing was performed per residents' preference for 3 of 4 sample residents (#2, #3, #4) reviewed for bathing. The findings were: 1. Review of resident #2's .ADL self-care performance . care plan last revised 10/21/25 showed the resident required 1 person assist for showers. The following concerns were identified:a. Review of the bathing record between 9/29/25 and 10/20/25 showed the resident received showers on 9/29/25 and 10/10/25 and was documented as refused on 10/6/25, 10/13/25 and 10/20/25. The record showed a shower was to be offered on an alternative day/time on 10/3/25, and 10/17/25; however, there was no evidence the bathing was offered, accepted, or refused.b. Interview with the resident on 10/23/25 at 9:55 AM revealed the s/he received a shower every 2 weeks, because that's how they have it set up. Further interview revealed s/he would prefer more showers if there was enough help.2. Review of resident #3's .ADL self-care performance . care…

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 and staff interview and medical record review, the facility failed to ensure there was sufficient nursing staff for 1 of 4 resident care units (Chapel) reviewed for sufficient staffing. The facility census was 77 and the Chapel unit census was 17. The findings were: 1. Review of resident #2's .ADL self-care performance . care plan last revised 10/21/25 showed the resident required 1 person assist for showers. The following concerns were identified:a. Review of the bathing record between 9/29/25 and 10/20/25 showed the resident received showers on 9/29/25 and 10/10/25 and was documented as refused on 10/6/25, 10/13/25 and 10/20/25. The record showed a shower was to be offered on an alternative day/time on 10/3/25, and 10/17/25; however, there was no evidence the bathing was offered, accepted, or refused.b. Interview with the resident on 10/23/25 at 9:55 AM revealed the s/he received a shower every 2 weeks, because that's how they have it set up. Further interview revealed s/he would prefer more showers if there was enough help.2. Review of resident #3's .ADL…

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 resident representative and staff interview, medical record review, and policy review, the facility failed to ensure the environment was free of accident hazards for 1 of 3 sample residents (#5) reviewed for falls. The findings were: 1. Review of the admission MDS dated [DATE] showed resident #5 had a BIMS score of 11/15 which indicated moderate cognitive impairment, and diagnoses which included diabetes mellitus, unspecified congestive heart failure, and morbid obesity. The resident was dependent for transfers and self cares, and was incontinent of bowel and bladder. Review of the care plan initiated on 7/30/25 showed the resident was at risk for falls, and had interventions which included If a fall occurs, alert provider and If a fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. The following concerns were identified:a. Interview with the resident's representative on 10/22/25 at 11:30 AM revealed she received a phone call from the resident's nurse on 9/9/25 at 2:03 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, and policy review, the facility failed to maintain accurately documented medical records for 2 of 3 sample residents (#1, #5) reviewed for falls. The findings were: . 1. Review of the admission MDS dated [DATE] showed resident #5 had a BIMS score of 11/15 which indicated moderate cognitive impairment, and diagnoses which included diabetes mellitus, unspecified congestive heart failure, and morbid obesity. The resident was dependent for transfers and self cares, and was incontinent of bowel and bladder. Review of the care plan initiated on 7/30/25 showed the resident was at a risk for falls, and If a fall occurs, alert provider and If a fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. The following concerns were identified:a. Interview with the resident's representative on 10/22/25 at 11:30 AM revealed she received a phone call from the resident's nurse, RN #1, on 9/9/25 at 2:03 PM and was told the resident had fallen during 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility investigation review, Office of Healthcare Licensing and Surveys ([NAME]) incident report log review, and policy and procedure review, the facility failed to report the results of abuse investigations within 5 working days to the State Agency for 4 of 11 sample residents (#7, #8, #9, and #10) reviewed for allegations of abuse. The findings were: 1. Review of a facility reported incident (FRI) dated 7/28/25 showed an allegation of verbal abuse between resident #7 and a staff member had occurred on 7/20/25 at 2:30 PM. The incident had been reported to the SSD on 7/28/25 at 12:00 PM and the administrator was made aware at 1:00 PM. The initial incident report was sent to [NAME] at 2:35 PM, and an investigation was begun. On 9/12/25 at 10:23 AM the [NAME] requested the investigation for the incident to be submitted. Further review showed no investigation was completed or reported by the facility as of 9/26/25.2. Review of a FRI dated 8/21/25 showed an incident of abuse between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility investigation review, [NAME] incident report log review, policy and procedure review, the facility failed to ensure a thorough investigation was completed and failed to report the results of the investigation to the State Agency for 4 of 11 sample residents (#7, #8, #9, and #10) reviewed for allegations of abuse. The findings were: 1. Review of a facility reported incident (FRI) dated 7/28/25 showed an allegation of verbal abuse between resident #7 and a staff member had occurred on 7/20/25 at 2:30 PM. The incident had been reported to the SSD on 7/28/25 at 12:00 PM and the administrator was made aware at 1:00 PM. The initial incident report was sent to [NAME] at 2:35 PM, and an investigation was begun. On 9/12/25 at 10:23 AM the [NAME] requested the investigation for the incident to be submitted. Further review showed no investigation was completed or reported by the facility as of 9/26/25.2. Review of a FRI dated 8/21/25 showed an incident of abuse between resident #8 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident representative, and staff interview, medical record review, and policy and procedure review, the facility failed to ensure resident representatives were notified of a change in condition for 1 of 3 sample residents (#1) who were transferred to the hospital. The census was 79. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15 which indicated intact cognition, and diagnoses which included coronary artery disease (CAD), heart failure, hypertension. Further review showed the resident had acute systolic (congestive) heart failure, need for assistance with personal care, and a colostomy. The following concerns were identified:a. Review of a progress note dated 9/25/25 showed .Resident presented with diaphoresis, pallor, c/o chest pain, constant coughing with bloody sputum, wheezes, course lung sounds, shortness of breath, and weakness. Vital signs: 145/82 manual, oxygen 97% 4L[liters] NC [nasal cannula], HR [heart rate] 79,…

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 staff interview, facility investigation review, and policy and procedure review, the facility failed to ensure residents were free from abuse from staff for 1 of 11 sample residents (#4) reviewed for allegations of abuse. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 3/15 which indicated severely impaired cognition, and diagnoses which included non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression. In addition, the resident had behaviors which included physical and verbal behavioral symptoms directed toward others that occurred 1 to 3 days in the look-back period, and other behavioral symptoms not directed toward others that occurred daily in the look-back period. Further review showed the resident was dependent on toileting hygiene and required partial/moderate assistance for toilet transfers. 2. Review of an incident dated 8/5/25 showed the SSD was contacted by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and resident representative and staff interview, the facility failed to provide services to prevent a decrease in mobility for 1 of 3 sample residents (#1) with limited mobility. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15 which indicated intact cognition, and diagnoses which included coronary artery disease (CAD), heart failure, hypertension, and acute systolic (congestive) heart failure. Further review showed the resident had a colostomy, a need for assistance with personal care, and the ability to walk 150 feet independently. Review of the medical record showed the resident was discharged to the hospital on 9/25/25. The following concerns were identified:a. Interview with the resident's representative on 10/1/25 at 10:06 AM revealed the resident had been able to walk with a walker when s/he admitted to the facility in January, but was discharged from therapy in March; and was now unable to walk.…

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 the facility's abuse investigation forms, State Survey Agency incident database review, policy and procedure review, and staff interview, the facility failed to implement policies and procedures for ensuring the reporting of 3 of 3 resident-to-resident altercations reviewed for allegations of abuse which involved resident #2, #3, #4, and #5. The findings were: 1. Review of the facility's policy Abuse, Neglect, and Exploitation, implemented on 4/1/24, 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 a nurse progress note, dated 12/21/24 and timed 5:18 PM, showed resident #4 and #5 were involved in an altercation which resulted in a minor injury to resident #4. Review of the state…

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

Based on medical record review, and staff interviews, and review of the staff schedule,the facility failed to ensure sufficient nursing staff was provided on 1 of 4 units (Courtyard) reviewed for medication administration. The findings were: 1. Review of resident #7's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of finasteride 5 milligrams (mg) related to benign prostatic hyperplasia with lower urinary tract symptoms, fluoxetine 10 mg related to depression, tamsulosin 0.4 mg related to benign prostatic hyperplasia with lower urinary tract symptoms, and protonix 40 mg related to gastrointestinal hemorrhage, at 6 AM. Further review showed the resident had a hold order on 10/10/24, which was signed off by the administrator, for losartan 100 mg, apply moisturizing lotion, and triamcinolone acetonide external cream 0.1% at 6 AM. 2. Review of resident #8's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of cyanocobalamin 1000 micrograms (mcg) related to…

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

Based on medical record review and staff interview, the facility failed to ensure medical records were accurately documented for 6 of 8 sample residents (#7, #8, #9, #11, #12, #14) reviewed for significant medication errors. The findings were: 1. Review of resident #7's medication administration record for October 2024 showed 10/10/24 the former DON signed off administration of finasteride 5 milligrams (mg) related to benign prostatic hyperplasia with lower urinary tract symptoms, fluoxetine 10 mg related to depression, tamsulosin 0.4 mg related to benign prostatic hyperplasia with lower urinary tract symptoms, and protonix 40 mg related to gastrointestinal hemorrhage, at 6 AM. 2. Review of resident #8's medication administration record for October 2024 showed on 10/10/24 the former DON signed off administration of cyanocobalamin 1000 micrograms (mcg) related to supplementation, metformin 1000 mg related to type II diabetes mellitus, multiple vitamins tablet related to supplementation, vitamin D3 capsule 25 mcg related to supplementation, acetaminophen 650 mg related to pain 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.

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 acceptable parameters of nutritional status for 2 of 5 sample residents (#5, #6) reviewed for nutrition. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #5 had short-term and long-term memory problems and diagnoses which included chronic kidney disease stage 3, non-Alzheimer's dementia, anxiety disorder, depression, muscle wasting and atrophy, and dysphagia. Further review showed the resident had weight loss greater than 5 percent and required supervision or touching assistance with eating. The following concerns were identified: a. Review of the resident's weight history showed s/he weighed 148 pounds on 5/22/24 and 120.3 pounds on 11/6/24, a weight loss of 18.71 percent. b. Review of the meal intake record from 10/9/24 through 11/7/24 showed the resident did not have a recorded meal intake for 16 out of 88 meals, was marked response not required was marked for…

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

Based on observation and resident and staff interview, the facility failed to ensure mail was delivered and unopened, including on Saturday. The census was 78. The findings were: 1. Interview with 5 residents during a group interview on 9/11/24 at 2 PM revealed the mail was locked up and the facility did not deliver mail on Saturdays. Further, the residents revealed mail was sometimes opened by the business office prior to delivery. 2. Interview with the activities director on 9/13/24 at 9:02 AM revealed she sorted through the mail and if it was not postcards or junk mail, she took it to the business office to open. Further, she revealed that mail was not delivered on Saturdays as the business office was closed. 3. Interview with business office manager on 9/13/24 at 10:20 AM revealed she was new to the facility and still learning what to do with the mail. She revealed she opened the mail to decide where it should go as some would be scanned into the computer for the resident's file and bills for the residents were paid out of their account. She revealed If it's personal mail it's…

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, resident, resident representative, and staff interview, and medical record review, the facility failed to ensure residents received services to maintain good personal hygiene for 3 of 5 sample residents (#8, #25, #53) reviewed for activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had a brief interview for mental status score of 15 out of 15, which indicated no cognitive impairment, and diagnoses which included polyneuropathy, cervicalgia or neck pain, osteoarthritis, and muscle wasting and atrophy. Further review showed the resident required substantial/maximal assistance with bathing. Review of the ADL (activities of daily living) care plan last revised on 4/8/24 showed I have told staff I prefer to have my showers, but I often may refuse my showers and only get 1 a week. If staff if [sic] making up my shower it may not be on the day or time I originally chose, but I am ok with that .BATHING/SHOWERING: I need 1 staff to…

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

Based on observation, resident, resident representative, and staff interviews, facility staff posting review, and facility assessment review, the facility failed to ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident on 3 of 4 resident care units (Deer, Chapel, Courtyard). The census was 78. The findings were: 1. Observation on the Courtyard Hall (secure unit) on 9/10/24 at 5:10 PM showed MA-C #1 assisted resident #68 who stood up from a recliner and walked across the room. The MA-C attempted to get the resident to sit in his/her wheelchair; however, she was only able to sit the resident sideways in the seat and was unable to reposition the resident safely in the wheelchair. The MA-C required assistance from a second person, and attempted to call 5 people for assistance, which were not answered. Interview with the MA-C revealed this is how it always is. Continued observation showed at 5:16 PM an unidentified non-clinical staff member opened the secure unit door and the MA-C asked…

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

Based on observation, staff interview, and policy review, the facility failed to ensure medications available for resident use were labeled appropriately in 2 of 5 medication storage areas (Rock Creek Hall medication cart, Deer Hall medication cart). The findings were: 1. Observation of Rock Creek Hall medication administration cart on 9/10/24 at 4:16 PM showed a Novolog insulin pen which was opened and undated. In the top-drawer of the cart, yellow stickers were available for medication labeling. 2. Observation of the Rock Creek Hall medication cart on 9/11/24 at 10 AM showed a Lantus SoloStar insulin pen and Toujeo SoloStar multidose insulin pen which were opened and undated. In the top-drawer of the cart, yellow stickers were available for medication labeling. 3. Observation of the Deer hall medication cart on 9/11/24 at 09:55 AM showed a Basaglar insulin pen which was opened and undated. In the top-drawer of the cart, yellow stickers were available for medication labeling. 4. Interview with the LPN #1 on 9/10/24 at 4:16 PM revealed she did not open the insulin pen and a yellow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents choice for advance directive for 1 of 18 sample residents (#50). The findings were: 1. Review of the electronic medical record (EHR) Clinical Resident Profile for resident #50 on [DATE] at 8:02 AM showed Code Status: (Advance Directives) ADC: Full Code. 2. Review of a physician's note for resident #50 dated [DATE] and timed 7:16 AM showed .Code Status: ADC FULL CODE . 3. Review of the physician orders for resident #50 showed an order for ADC: Full Code which was active with a start date of [DATE]. 4. Review of the [DATE] WyoPOLST-Providers Orders for Life Sustaining Treatment signed by resident #50 showed Cardiopulmonary Resuscitation (CPR) was marked DNR/Do Not Attempt Resuscitation (Allow Natural Death). 5. Interview with the DON on [DATE] at 9 AM confirmed resident #50 had elected a code status of DNR and the EHR indicated Full code. Further interview revealed the facility should follow the resident's code status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure preadmission screening was performed and was accurate for 2 of 18 sample residents (#8, #59) with qualifying diagnoses. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had diagnoses which included depression and bipolar disease. Review of the resident's active diagnosis report showed the resident had diagnoses which included mood disorder due to known physiological condition with mixed features and did not have a primary diagnosis of dementia. The following concerns were identified: a. Review of the PASARR Level I assessment completed on 3/8/23 showed the resident had a qualifying diagnosis of mood disorder due to known physiological condition with mixed features and was marked no for all mental illness screening questions. Further review showed the PASARR Level I screening summary indicated no evidence of mental illness or intellectual disability. A PASARR level II was not triggered or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medications available for resident use were not expired in 1 of 3 medication storage areas (medication storage room). The findings were: 1. Observation of the medication storage room on [DATE] at 5:12 PM showed 2 bottles of Geri-mox (liquid antacid) on the shelf with an expiration date of 3/2024. 2. Interview with the DON on [DATE] at 5:19 PM confirmed the medications were available for resident consumption and had expired. They were immediately removed by the DON at that time. 3. Review of the facility policy Medication Storage revised [DATE] showed It is the policy of this facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .8. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consult pharmacist for discontinued, outdated, defective, or deteriorated medications…

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 MDS 3.0 Resident Assessment Instrument (RAI) manual review, the facility failed to ensure MDS assessments were accurate for 2 of 4 sample residents (#37, #41) reviewed for MDS discrepancies. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #37 was coded as taking anticoagulant and antiplatelet medications. Review of the physician orders showed the resident received Plavix (antiplatelet medication) 25 mg (milligrams) by mouth, one time daily for unspecified sequelae of unspecified cerevrovascular disease; however, there was no indication the resident received an anticoagulant medication. 2. Review of the admission MDS assessment dated [DATE] showed resident #41 was coded as not taking an anticoagulant; however, review of physician orders showed the resident received Rivaroxaban [anticoagulant] 20 mg once per day for a diagnosis of atherosclerotic heart disease of native coronary artery. 3. Interview with the MDS…

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, resident and family interviews, and review of facility policies, the facility failed to ensure residents and their representative(s) participated in the development of the care plan for 2 of 2 sample residents (#8, #41) reviewed for care planning. The findings were: 1. Review of the 2/14/24 initial MDS assessment showed resident #8 was admitted on [DATE] and had a BIMS score of 15 out of 15, indicating intact cognition. Review of a progress noted dated 2/12/24 showed Resident recently discharged return not anticipated and it was a failed discharge. Resident readmitted within 72 hours of discharge. Care plan reviewed from previous stay prior to discharge and updated to reflect any changes to resident's care plan. The following concerns were identified: a. During an interview on 4/2/24 at 10:47 AM the resident stated s/he had not been invited to a care conference to participate in the development of a care plan. b. Review of the medical record showed a care conference note…

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 residents received timely care in accordance with professional standards for 1 of 24 sample residents (#15). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #15 had severe cognitive impairment and diagnoses which included non-Alzheimer's dementia, anxiety, history of falls, muscle wasting and atrophy, and a history of traumatic brain injury. The resident required extensive physical assistance for bed mobility, locomotion, and dressing and total physical assistance for transfers, eating, toileting, hygiene, and bathing. Further review showed the resident had no falls since admission or the prior assessment. Review of the Behavior care plan last revised on 7/19/23 showed interventions which included .Floor mat or spare mattress will be placed on floor next to [resident's name] bed to ensure s/he is able to safely roll and reposition out of [his/her] bed.…

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

Based on observation, staff interview, and policy review the facility failed to provide call light accessibility for 1 of 24 initial pool residents (#15). The findings were: 1. Observation on 10/2/23 at 5:10 PM showed resident #15 was observed on the floor calling out for help. Further observation showed the call light location could not be found. 2. Interview with CNA #3 and #4 on 10/4/23 at 3:10 PM revealed the resident had a pull type call light; however, they were unsure if the resident was able to use it. 3. Observation on 10/4/23 at 3:12 PM showed the resident was lying in bed, awake. A full sized mattress was against the wall and a fall mat was on the floor beside bed. Further observation showed the call light was clipped to itself and placed above the mattress on the wall, out of the resident's reach. 4. Observation with the DON on 10/4/23 at 4:15 PM showed the resident was lying in bed and the call light was on top of a full sized mattress which was leaning against the wall. The call light was clipped to itself and positioned just below the call light switch, out of reach…

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.