Thermopolis Rehabilitation and Wellness

Based on medical record review, staff interview, state survey agency incident database review, and policy and procedure review, the facility failed to accurately and timely report allegations of abuse for 1 of 13 sample residents (#1) reviewed for reportable allegations. The findings were:1. Review of a progress note for resident #1 dated 1/3/26 and timed 3:26 PM showed This nurse was sitting in the dining room with residents. [resident #1] was walking around calmly as normal. [S/He] got close to another resident, and without any queue, wound back with a clenched fist and punched a sitting resident in the face. Resident was immediately redirected and didn't seem to recall any of the situation seconds prior. Resident was immediately removed from situation, and placed on one on one. Resident has no recollection of event so only intervention is one on one at this time . 2. Review of an Allegation of Resident to Resident Abuse for resident #2 dated 1/3/26 and timed 3 PM showed Resident was sitting in dining room when another resident punched [him/her] in the face. Resident did nothing…

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, medical record review, and manufacturer's instruction review, the facility failed to ensure appropriate use of mechanical lifts during 1 random observation of mechanical lift transfers for a sample resident #3. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #3 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, morbid obesity, anxiety disorder and post-traumatic stress disorder. Further review showed the resident was dependent on staff for chair/bed-to-chair transfer. Review of the care plan last revised on 8/15/2025 showed the resident had an ADL function decline related to reduced mobility due to his/her morbid obesity, weakness, and chronic health conditions, and used a mechanical lift for transfers. The following concerns were identified:a. Observation on 11/19/25 at 3:20 PM showed two unidentified CNA's, and RN #1 entered the resident's room 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 residents were free from significant medication errors for 1 of 11 sampled residents (#40). The findings were: 1. Review of the 11/14/25 admission MDS assessment showed resident #40 had a BIMS of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, atrial fibrillation. hypertension, presence of cardiac pacemaker, hypo-osmolality and hyponatremia. Further review showed the resident received a vasopressor medication, midodrine, which was administered based on blood pressure parameters. Review of the physician orders dated 11/14/25 showed the resident received midodrine 5 milligrams (mg) by mouth three times daily with meals for hypotension. The following concerns were identified.a. Review of the physician orders dated 11/14/25 showed May stop midodrine if blood pressure above 110.b. Review of the medication administration record showed the resident's blood pressure prior to his/her scheduled noon dose of midodrine administration on 11/16/25 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.

Based on observation, staff interview, and review of policy and procedures, the facility failed to ensure effective infection prevention practices were implemented during one random observation of linen transportation. The findings were: 1. Observation on 11/17/2025 at 2:25 PM showed RN #3 walked down the East hall with unbagged soiled linen in her hands and transported them to the soiled laundry bin. 2. Interview with the infection prevention coordinator and NHA on 11/20/25 at 11:35 AM revealed soiled linen should be bagged before being removed from rooms and transported to the soiled laundry bin. 3. Review of the Centers for Disease Control and Prevention standards of practice titled Laundry and Bedding, last revised 1/08/24, showed soiled laundry should be bagged prior to transporting to the soiled linen room. 4. Review of the facility policy titled Infection Control Policies and Practices, last revised 5/30/23, showed .6. The Executive Director or Governing Board, through the QAPI and infection control committees, have adopted our infection control policies and practices, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure physician notification of a resident change in condition for 1 of 4 sample residents (#1) reviewed for a change of condition. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a mental status that was not assessed and diagnoses which included diabetes mellitus and non-Alzheimer's dementia. The following concerns were identified:a. Review of the medication administration record for September 2025 showed the resident received insulin degludec, blood sugar check twice per day, Januvia 100 mg daily, and metformin 100 mg twice per day for diabetes mellitus which were all discontinued on 9/9/25. b. Review of a progress dated 9/7/25 and timed 11:53 PM showed Pt. [patient] observed slumped in recliner. Diaphoretic with AMS [altered mental status]. Unable to follow simple commands. VS [vital signs] 100F [Fahrenheit], 88 FSBS [fingerstick blood sugar], 99/47BP [blood…

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 receive quality of care and treatment to meet the resident's mental, physical, and psychosocial needs for 1 of 4 sample residents (#1) reviewed for diabetic treatment. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a mental status that was not assessed and diagnoses which included diabetes mellitus and non-Alzheimer's dementia. The following concerns were identified:a. Review of an admission physician note dated 6/17/25 showed the resident had type 2 diabetes mellitus and the assessment/plan included a glucose monitor to his/her left arm to preventfinger stick blood sugar monitoring 3 times per day.b. Review of the medication administration record for September 2025 showed the resident received insulin degludec, blood sugar check twice per day, Januvia 100 mg daily, and metformin 100 mg twice per day for diabetes mellitus which were all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident representative and staff interview and policy and procedure review, the facility failed to meet professional standards of quality for 1 of 3 sample residents (#1) reviewed for diagnostic service orders. The findings were: 1. Review of the re-entry MDS assessment dated [DATE] showed resident #1 had severely impaired cognitive skills, did not ambulate, and required substantial/maximal assistance for transfers. Resident #1 had diagnoses which included presence of left artificial hip joint, difficulty in walking, and neurocognitive disorder with Lewy bodies. The following concerns were identified: a. Review of a progress note dated 6/6/25 and timed 2:39 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers . b. Review of a progress note dated 6/7/25 and timed 2:46 AM showed .PT is seeing resident and has requested 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident representative and staff interview, and policy and procedure review, the facility failed to meet the needs of residents with regard to the quality and/or timeliness of providing radiology or other diagnostic services for 1 of 3 sample residents (#1) reviewed for diagnostic service orders. The findings were: 1. Review of the re-entry MDS assessment dated [DATE] showed resident #1 had severely impaired cognitive skills, did not ambulate, and required substantial/maximal assistance for transfers. Resident #1 had diagnoses which included presence of left artificial hip joint, difficulty in walking, and neurocognitive disorder with Lewy bodies. The following concerns were identified: a. Review of a progress note dated 6/6/25 and timed 2:39 AM showed .PT is seeing resident and has requested staff to see about getting an x-ray to the left hip d/t very tight tension and limited ROM. Resident will work on improving LLE strength and ROM for glider transfers . b. Review of a progress 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 review of facility policies and CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 1 of 5 sample residents (#11) reviewed for immunizations. The findings were: 1. Review of the medical record showed resident #11 was admitted on [DATE] and was [AGE] years old. Review of the 9/21/23 initial and 3/17/24 quarterly MDS assessments showed the resident was not up to date on pneumococcal immunizations. The reason was not offered. Further review of the medical record showed the resident received the following pneumococcal vaccines: PPSV23 on 6/10/2003 and PPSV23 on 7/18/2008. There lacked evidence the resident was offered a pneumococcal immunization since admission. 2. During an interview on 6/27/23 at 1:39 PM the DON and DDCO stated the resident had received two doses of PPSV23 and confirmed there lacked evidence to show the resident was offered a pneumococcal vaccine since…

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

Based on medical record review and staff interview, the facility failed to ensure a written notice of transfer was provided to the resident or resident's representative for 2 of 2 sample residents (#36, #41) who were hospitalized . The findings were: 1. Review of progress notes showed resident #36 was transferred to the hospital on 4/11/23. The resident returned to the facility on 4/17/23. Review of the medical record showed a copy of a Facility notice of Discharge form that was e-mailed to the Ombudsman on 4/13/23. However, there lacked evidence the resident or resident's representative received written notice of the transfer. 2. Review of progress notes showed on 3/20/23 resident #41 was transferred to the emergency room. A progress note dated 3/21/23 showed the resident was admitted to the hospital, and would be discharged to hospice care in another city. Review of the medical record showed a copy of a Facility notice of Discharge form that was e-mailed to the Ombudsman on 3/23/23. However, there lacked evidence the resident or resident's representative received written notice 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 observation, medical record review, resident interview, and staff interview, the facility failed to ensure ostomy care was provided according to the care plan for 1 of 1 residents with an ostomy (#24). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #24 entered the facility on 10/18/22 and had a BIMS score of 15 out of 15, indicating intact cognition. Bowel elimination showed the resident had an ostomy. The diagnoses included personal history of malignant neoplasm of large intestine, diabetes mellitus, and muscle weakness. Review of the current care plan showed and intervention last revised on 12/2/22: Monitor Colostomy every shift and as needed; dressing change per protocol. Provide Colostomy care and monitor for any skin breakdown, and an intervention last revised on 10/27/22: [Resident name] has an alteration in gastro-intestinal status r/t [related to] Colostomy (history of Colon Cancer) and GERD. [Resident name] will remain free from discomfort,…

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 residents received a gradual dose reduction (GDR), unless contraindicated, for psychotropic medication for 1 of 5 sample residents (#5) reviewed for unnecessary medications. The findings were: 1. Review of the 2/25/23 quarterly MDS assessment showed resident #5 had diagnoses that included non-Alzheimer's dementia and anxiety disorder. Further, the resident received an antipsychotic on 7 days during the look-back period and a GDR was not attempted, nor did the physician document a contraindication. Review of physician orders showed the resident received Ziprasidone HCl (antipsychotic, brand name Geodon) 60 mg once per day plus 40 mg once per day since 7/26/22. The following concerns were identified: a. Review of the medical record showed no evidence a GDR of the Ziprasidone HCL was attempted. b. Review of a physician's progress note dated 2/14/23 showed Pharmacy review performed with recommendation GDR Geodon. The patient has been decreased to 40 mg BID [twice per day] in the last several days. However,…

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, and staff interview, the facility failed to ensure medications for resident use were not expired in 1 of 3 medication storage units ( secure unit medication cart). The findings were: 1. Observation on [DATE] at 2:44 PM of the secure unit medication cart with LPN #1 showed 54 tablets of hydrocodone-acetaminophen 5-325 mg tablets had expired 3/2023. Interview with the LPN at that time confirmed the medication was for resident use and expired. 2. Interview with the DON on [DATE] at 2:54 PM revealed it was the expectation for the nurses to check the expiration date and dispose of the medication if expired. 3. Interview with the assistant executive director on [DATE] at 4:51 PM revealed the facility did not have a policy related to prescription medication expirations.